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392 Cards in this Set
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What is the normal resp rate in neonates
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30-60
rate consistently >60 should be evaluated pg734 |
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T/F
Neonates are obligate nasal breathers |
True
pg734 |
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T/F
neonates increase minute ventilation through an increase in inspiratory volume |
FALSE
increased minute ventilation is almost entirely from an increase in rate pg734 |
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When should periods of apnea be in neonates be evaluated? (3)
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>20sec
with bradycardia, cyanosis change in muscle tone pg734 |
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CNS conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (3)
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ICH
Meningitis elevated ICP pg735 table 111-3 |
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EENT conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (1)
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Nasal obstruction
(choanal atresia or stenosis) pg735 table 111-3 |
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Pulmonary conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (1)
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Pneumonia
pg735 table 111-3 |
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Cardiac conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (2)
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SVT
Heart failure pg735 table 111-3 |
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GI conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (3)
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Volvulus
Intussusception Incarcerated Hernia pg735 table 111-3 |
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GU conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (3)
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testicular torsion
penile hair tourniquet paraphymosis pg735 table 111-3 |
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Musculoskeletal conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (2)
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hair tourniquet of finger/toe
NAT pg735 table 111-3 |
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Infectious conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (3)
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sepsis
pneumonia meningitis pg735 table 111-3 |
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metabolic conditions assoc with uncontrollable crying, irritability, and lethargy in neonates (3)
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congenital adrenal hyperplasia
hypoglycemia inborn errors of metabolism pg735 table 111-3 |
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Crying for 3 hours per day for 3 days per week or more over a 3-week period and causes significant parental distress
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Colic
pg 735 |
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although colic is a benign condition it is a known risk factor for what?
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Nonaccidental trauma - creates significant caregiver stress and fatigue. Overnight admission if home safety cannot be assured.
pg735 |
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Macular, salmon or pink colored lesions on the nape of the neck or glabellar region
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nevus flanneus (stork bites), on the face likely to fade
pg735 |
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dark blue-black macular patches, common on lumbar and sacral areas
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Mongolian spots
pg735 |
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small erythematous or yellow papules and pustules on the face trunk or extremities in the first few days of life
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Erythema Toxicum
unlike staph/strep, no ttp, warmth, induration pg735 |
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small papules or pustules on the face and upper trunk usually beginning in the first few weeks of life
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Neonatal acne, related to transplacental hormones, resolves without tx
pg735 |
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Bradycardia in the neonate is almost always secondary to what?
|
respiratory failure and hypoxia,
typically symptomatic in 1st week of life or after the 2nd pg736 |
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Congenital adrenal hyperplasia should be suspected in all neonates presenting in shock. what are the s/s?
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signs of virilization or ambiguous genitalia plus hyper pigmentation,
hyponatremia and hyperkalemia pg 736 |
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If suspected, what is the initial treatment of congenital adrenal hyperplasia
|
hydrocortisone 12.5-25mg IV/IM/IO in addition to standard resuscitative measures
pg736 |
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abx of choice for empiric treatment of sepsis in neonates?
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ampicillin 50mg/kg and gentamicin 2.5mg/kg
pg736 |
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This diaper rash appears macular and erythematous with sharply demarcated edges
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Contact dermatitis
treated with air drying and zinc oxide pg736 |
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This diaper rash appears as an erythematous plaque with scalloped border and a sharply demarcated edge studded with satellite lesions
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Candidal dermatitis
tx with nystatin cream qid or at each diaper change pg736 |
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infant started abx for OM now has white and flaky lesions on the tongue, lips, gingiva, and bucal mucous membranes
|
Oral candidal lesion (Thrush)
tx with oral nystatin or gentian violet pg736 |
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mom c/o unconsolable crying in her infant. After a thorough hx and physical, no source is revealed and the baby stopped during visit,, what next
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Nothing, reassure the parents and f/u with PCM
pg736 |
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Respiratory difficulty when quiet and improves during crying suggests what?
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Choanal atresia
pg737 |
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T/F OTC cold medications are indicated in children > 1yo
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FALSE: CI <24mo, cough is primary protective reflex
pg737 |
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inspiratory sound like snorting or snoring localized to the nose or nasopharynx
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stertor, usually benign
pg737 |
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Noisy, crowing inspiratory sounds which usually decrease during first year of life
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laryngomalacia; most common cause of stridor in neonates
pg737 |
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stridor worsening with crying or increased activity suggest what (2)
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tracheomalacia or subglottic hemangioma
pg737 |
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stridor accompanied by feeding difficulties suggests what (3)
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vascular ring, laryngeal cleft, or tracheoesophageal fistula
pg737 |
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stridor with hoarseness or weak cry suggests what
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vocal cord paralysis
pg737 |
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What are infectious causes of stridor (3)
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croup, epiglotitis, and abscess
pg737 |
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Apnea is a cessation of respiration for ___ sec or less with bradycardia, cyanosis, or change in muscle tone
|
20
pg737 |
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cyanosis associated with rapid but unlabored breathing (quiet tachypnea) is most likely a result of what
|
Cyanotic congenital heart disease
Pg737 |
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cyanosis assoc with irregular or shallow breathing may be a sign of what systemic disease (4)
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sepsis, meningitis, cerebral edema, or intracranial hemorrhage
pg737 |
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What is the most common site of infection in neonates?
|
Lung - pneumonia
pg737 |
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Factors that predispose to complications of bronchiolitis include what (3)
|
prematurity and underlying pulmonary or congenital heart disease
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Bronchiolitis caused by RSV is associated with apnea, especially in neonates and preterm <34wk. when does it usually present
|
the first 3 days of life
pg738 |
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All infants <1 month early in the course of potential bronchiolitis should undergo what?
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nasal wash for rapid RSV testing, if pos admitt
pg738 |
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True tachypnea (rate of ____) or grunting should always be considered a medical emergency
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60 breaths/min
pg737 |
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neonatal PNA initially URI progressing to resp distress and difficulty feeding
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Viral PNA - RSV,adenovirus,influenza, parainfluenza. often indistinguishable from bronchiolitis
pg738 table 111-5 |
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neonatal PNA often presents with nonspecific systemic symptoms (fever, FTT, organomegaly, resp distress)
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Mycobacterium tuberculosis
skin testing no sensitive in neonates, routine anti-TB tx pg738 table 111-5 |
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in addition to neonatal PNA this may cause paroxysms of cough, +/- cyanosis and post-tussive emisis in otherwise well-looking infant
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Bordetella pertussis - whoop not present in neonates, admit and monitor for severe adverse effects
pg738 table 111-5 |
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neonatal PNA usually occurs after 3 wk of age with conjunctivitis and staccato cough
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Chlamydia
tx is macrolides pg738 table 111-5 |
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The diagnosis of bronchiolitis is usually made clinically with the constellation of (3)
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nasal discharge, rhonchi, and wheezing
pg739 |
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T/F CXR are not routinely necessary in bronchiolitis and may lead to unnecessary use of abx due to areas of atelectasis, which may mimic infiltrate
|
TRUE
pg739 |
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in the setting of high fever and bronchiolitis what should be considered?
|
UA, as up to 4% may have assoc UTI
pg739 |
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Bronchiolitis has an increased risk to develop progessive or life-threatening illness with what factors (4)
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born premature, underlying hear/lung disease, <3mo old, initial O2 sat <92%
pg739 |
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T/F Bronchodilators and abx are the mainstay of bronchiolitis treatment
|
FALSE
pg739 |
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What ductal-dependent lesions present in the first week of life with shock, tachypnea, acidosis? (2)
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hypoplastic left heart syndrome, coartation of the aorta - as the ductus arteriosus closes
pg739 |
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muscle weakness preceded by constipation, followed by a weak cry and feeding difficulties
|
infantile botulism
ocular palsies, apnea, hypotonia, and lethargy are late symptoms pg739 |
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This is the most commonly correctible cause of vomiting in newborns, classically presenting btwn 6 wk and 6mo of age
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Pyloric stenosis - firm olive shaped mass under liver edge, MC diagnosed with US
pg740 |
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Sudden onset of bilious vomiting in the first month of life suggests what
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malrotation and volvulus
Bilious vomiting is always considered a surgical emergency pg740 |
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What accounts for most abdominal surgical emergencies from 2mo to 1yo (2)
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incarcerated hernia and intussusception
pg740 |
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Pneumatosis intestinalis (intraluminal air) and hepatic portal air are the classic x-ray findings of what
|
necrotizing enterocolitis, tx with bowel rest and broad spectrum abx
pg740 |
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What is the MC cause of blood in the diaper in the first 2-3 days of life?
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swallowed maternal blood
pg740 |
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After the first few days of life, most causes of blood in the diaper are idiopathic. What else should be considered (4)
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coagulopathies, necrotizing enterocolitis, allergic/infectious colitis, congenital defects
pg740 |
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What % of body wt loss is Moderate dehydration
|
6-9%
pg741 table 111-6 |
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T/F Oral rehydration should be attempted in the mildly dehydrated child
|
True - attempt in children <5% dehydrated
pg741 |
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What should be considered if the infant that has not passed stool in the first 48 hours of life (3)
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intestinal stenosis, Hirschprung disease, meconium ileus assoc with cystic fibrosis
pg741 |
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Constipation within the first month of life suggests what (4)
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Hirschprung, hypothyroidism, anal stenosis, anteriorly displaced anus
pg741 |
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When evaluating c/o constipation the absence of feces on rectal exam, a tonic sphincter, and an abrupt change in luminal size on barium enema suggests what
|
hirschprung's disease, confirmed by rectal biopsy
pg741 |
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constipation with feeding problems, a weak/hoarse cry, large ant fontanelle, hypothermia, hypotonia and peripheral edema suggest what
|
hypothyroidism
pg 742 |
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Physiologic jaundice is characterized by bilirubin rising at a rate of ____per 24 hours, with a peak of _____during days 2-4, and a decrease to____ by 5-7 days
|
<5mg/dL
5-6mg/dL <2mg/dL pg742 |
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What are the MC causes of jaundice seen in the ED (4)
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physiologic, breastfeeding, breast mild, infection
pg742 |
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Exam of jaundice should not the degree, which progresses in a cephalocuadal direction. When is scleral icterus noted?
|
Serum bilirubin >6mg/dL
pg742 |
|
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What is conjugated hyperbilirubinemia
|
inability to excrete bilirubin in the bile/intestines as a result of biliary atresia or hepatitis.
pg743 |
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usually presents later in the neonatal period with jaundice, colic stools and dark urine
|
Conjugated hyperbilirubinemia
pg743 |
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What is thought to be the cause of breast milk jaundice?
|
presence of substances that inhibit glucuronyl transferase, treated with phototherapy
pg743 |
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This type of jaundice usually occurs when the newborn is exclusively breastfed and the milk supply is still inadequate
|
Starvation jaundice
pg743 |
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At a minimum, what should be ordered when evaluating the jaundiced neonate
|
direct and indirect bilirubin to distinguish unconjugated from conjugated hyperbilirubinemia
pg743/744 |
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How do you differentiate dacryostenosis from conjunctivitis?
|
The presence of conjunctival inflammation
pg744 |
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The finding of vesicles anywhere on the body in assoc with neonatal conjunctivitis suggest what
|
herpes simplex infection that warrants full sepsis eval with CSF cultures and acyclovir
pg744 |
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mild to severe conjunctival hyperemia with a thick mucopurulent discharge and pseudomembrane formation
|
chlamydial conjuctivitis
pg744 |
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What is the mc cause of conjunctivitis onset btwn 3-5 days of life?
|
Gonococcal
pg744 |
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by the end of the first week of life and throughout the first month what is the mc cause of conjunctivitis
|
Chlamydia
pg744 |
|
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Why is ceftriaxone not recommended for the treatment of gonococcal ophthalmia neonatorum
|
can displace bound bilirubin and precipitate kernicterus, cefotaxime recommended
pg744 |
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What is the definition of fever in the first month of life?
|
rectal temp of 38C or 100.4F measured by caretaker or health care professional.
pg744 |
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Initial tx of a neonate with suspected bacterial septicemia or meningitis includes what
|
Ampicillin 50mg/kg for group B Strep and Listeria
Gentamicin 2.5mg/kg for E. coli pg745 |
|
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When a gram-negative meningitis is strongly suspected gentamicin should be replaced with what
|
cefotaxime or ceftazidime which have better CNS penetration
pg745 |
|
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rhythmic myoclonic jerks when infant is drowsy or sleeping and can be suppressed with touching/waking
|
benign sleep myoclonus
pg745 |
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T/F - SIDS is a diagnosis of exclusion
|
True
pg745 |
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SIDS-like presentation in the first month of life should raise suspiscion of what?
|
Congenital heart disease, NAT, metabolic disorder
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T/F - infant with rigor mortis, livedo reticularis, pH<6, or hypothermic without exposure should not be resuscitated?
|
True
pg746 |
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in general, the infants body should not be manipulated or photographed after death has been declared without approval from whom?
|
coroner
pg746 |
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Sudden unexplained infant death must be reported as soon as possible to the coroner. Does the treating physician sign the death certificate?
|
No, cause of death not determined until investigation is finished. treating physician completes the reporting form only.
pg746 |
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Mom is concerned because her son suddenly stopped breathing, turned blue and went limp. At presentation child appears normal. What are you concerned for?
|
ALTE-episode frightening caregiver with some combination of apnea, color change, changes in muscle tone, and choking or gagging.
pg746 |
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Mom is concerned because her son suddenly stopped breathing, turned blue and went limp. At presentation child appears normal. Is ALTE an appropriate diagnosis?
|
No, ALTE is a symptom not dx.
pg746 |
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When are apneic pauses considered pathologic? (4)
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>20sec or assoc changes in color, tone, or heart rate
pg747 |
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what is apnea of prematurity
|
a disorder in the control of breathing, occurs in 25%
pg747 |
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typically cyanosis key be observed in normal newborns. what is the distribution
|
perioral or distal(acrocyanosis)
pg747 |
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This is among the most common and controversial potential sources for ALTE
|
GERD
pg747 |
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What may be the first presenting symptom of bronchiolitis?
|
apnea
pg747 |
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What are among the most concerning possible causes of an ALTE (3)
|
Suffocation, inflicted head injury, poisoning
pg747 |
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How may pertussis present in an infant <3mo old?
|
isolated apnea may be only symptoms. classic presentation often absent or blunted.
pg748 |
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What should always be considered in an infant presenting with an afebrile ALTHE? (3)
|
bacteremia, meningitis, UTI
pg748 |
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The approach to ALTE is categorized in what 3 discrete groups?
|
1)clear cause from hx and PE
2)dx not clear, but appear unstable 3)well-apearing with concerning hx, but exam normal/noncontributory pg748 |
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What is the definition of Serious Bacterial Illness?
|
bacterial infection in neonates, infants, and young children with high M/M if not treated.
|
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What is the threshold for concerning fever in <2 or 3 months old?
|
38C, 100.4F
pg750 |
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What is the threshold for concerning fever in 3-36 months old?
|
39C, 102.2F
pg750 |
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What is the dosage for tylenol
|
15mg/kg (max 80mg/kg) q4-6 hours PO or PR.
pg750 |
|
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What is the dose of motrin
|
10mg/kg (max 40mg/kg) q6-8 hours
pg750 |
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The presence of fever >or= to 39C and urnine suggestive of infection indicates what?
|
renal parenchymal involvement, or Pyelonephritis
pg751 |
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Approx 5 to 10% of febrile infants with a UTI will have what?
|
bacteremia
pg751 |
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What is the incidence of bacteremia/sepsis in febrile infants <or= 3 months old
|
2-3%
pg751 |
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What is the MC cause of bacteremia/meningitis in infants <or= 3mo old
|
E. Coli, Group B Streptococcus, and Listeria monocytogenes.
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What is the incidence of SBI in ill-appearing neonates and those identified as high risk
|
13-21%
However viral is most frequent cause of infection <3mo old. pg751 |
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|
administration of Hib and pneumovax have decrease occult bacteremia rate of well-appearing, febrile children to what percent
|
from 2-3% to 0.5 to 0.7%
pg751 |
|
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|
due to incomplete sinus formation, sinusitis is uncommon in what age?
|
<3yo
pg751 |
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What is the gold standard for diagnosis of pneumonia
|
CXR
pg751 |
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What is the incidence of bacterial meningitis in infants <3mo old?
|
1%, mc cuase E.coli, Group B Strep, and L. Monocytogenes
pg751 |
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What is the most common cause of meningitis in children >3mo old? (3)
|
S. pneumoniae, Neisseria meningitidis, Staph aureus
pg751 |
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What level of CSF WBC suggests meningitis in neonates and children >1mo old?
|
neonates - >30
child >1mo - >10 pg751 |
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A negative bacterial meningitis score does not exclude some treatable causes of meningitis/encephalitis such as what? (2)
|
herpesvirus and Lyme disease
pg751 |
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Infants with aseptic meningitis should be hospitalized b/c they are at greater risk of what? (2)
|
dehydration and subsequent neurologic and learning disabilities.
pg751 |
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If a child is to be discharged with a likelihood of viral meningitis it is wise to do what? (2)
|
ceftriaxone 100mg/kg and ensure follow-up in 24 hours
pg752 |
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If the PE does not identify a source of infection, decision making is based on what? (2)
|
first age, then degree of fever
pg752 |
|
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|
when evaluating febrile preterm infants, what correction for age should be taken?
|
count the age by estimated post conception date and not by the actual delivery date for the first 90 days.
pg752 |
|
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|
what is the least sensitive of the three guidelines for SBI?
|
Rochester - miss 1% and does not include LP as a diagnostic test
|
|
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|
What are the 3 guidelines for evaluation of low-risk febrile children for SBI
|
Rochester criteria, Philadelphia Protocol, and the Boston criteria
|
|
|
|
Which criteria is recommended for treatment and disposition of the low-risk febrile infant?
|
Philadelphia protocol - sensitivity 98% and NPV 99.7%
pg752/754 |
|
|
|
What is the evaluation and tx of a well appearing febrile infant 0-30 days old with no source clinical source of infection and immunizations current?
|
full sepsis testing, admission
Ampicillin 50mg/kg AND cefotaxime 50mg/kg or gentamicin 2.5mg/kg pg735 table 113-3 |
|
|
|
What is the evaluation and tx of a well appearing febrile infant 31-60 days old with no source clinical source of infection and immunizations current?
|
full sepsis eval
if any of the philadelphia protocol are not met, admit ceftriaxone 50mg/kg normal CSF or 100mg/kg signs of meningitis |
|
|
|
Why do you avoid ceftriaxone in infants < 1month old
|
may displace bilirubin and worsen hyperbilirubinemia
pg753 |
|
|
|
T/F Bacterial pharyngitis is likely under the age of 3 years old?
|
FALSE
pg754 |
|
|
|
IAW American Academy of Pediatrics practice guidelines what population is tested for UTI? (3)
|
All girls <2yo
all uncircumcised boys<2yo circumcised boys<1yo pg755 |
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Children with positive blood cultures for ____ should be admitted for abc therapy.
|
N. meningitidis or methicillin-resistant S. aureus or s.pneumoniae. pg755
|
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|
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What is the treatment for Group A strep in children >36mo old?
|
Amoxicillin 40-50mg/kg or azithromycin 10mg/kg
pg755 |
|
|
|
what age is peak incidence of OM
|
6-18mo old
pg756 |
|
|
|
What are the most common pathogens causing OM
|
S. pnemoniae(31%), Hib(56%), M catarrhalis
pg756 |
|
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|
What is the most important step in reducing unnecessary abx for acute OM?
|
proper dx, no tx recommended for OM with effusion.
pg756 |
|
|
|
What three components are required for acute OM?
|
onset<48hr,
middle ear effusion-buldging TM middle ear inflammation-at least one-fever, otalgia, irritability in infant, red TM pg756 |
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|
What is an alternative treatment for cerumen impaction in the ED
|
1ml of docusate in ear canal for 15min, then irrigate.
pg756 |
|
|
|
What is the tx for acute OM?
|
amoxicillin 80-90mg/kg for 5 to 7 days.
|
|
|
|
Ill appearing, recurrent OM (within 2-4wk), immunocompromised, and age <___ are indications for immediate abx use in OM?
|
<6mo, however consider another source if <2mo of age
pg758 |
|
|
|
What is the definition of OM with effusion
|
fluid in the middle ear without clinical s/s of inflammation or acute illness.
pg758 |
|
|
|
What is the mc organism in otitis externa?
|
Pseudomonas, S. Epidermidis, and S. aureus
pg759 |
|
|
|
child with severe left ear pain, facial paralysis, meningeal signs and temp of 102F
|
malignant otitis externa - osteomyelitis of the ear canal
pg759 |
|
|
|
What it the treatment of otitis externa?
|
mild - acetic acid drops TID
ofloxacin/ciprofloxacin BID pg759 |
|
|
|
Is mastoiditis likely with a normal middle ear exam?
|
No!
pg760 |
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|
Mastoiditis can cause palsies of which CN
|
VI - abducens
VII - facial pg760 |
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|
|
What is the treatment of mastoiditis?
|
IV ampicillian/sulbactam (unasyn) 100mg/kg q6hrs until physical signs have diminished, then 2 week oral course
pg761 |
|
|
|
white, slightly raised nodules seen most commonly midline at the junction of the soft and pard palate of neonates?
|
Epstein pearls - remnants of embryonic development, most resolve spontaneously.
pg775 |
|
|
|
Mom concerned for 'rash' on child's tongue. you see an area of erythema and atrophy of the papillae of the tongue surrounded by a serpiginous, elevated white/yellow border on the anterior 2/3
|
Geographic tongue-benign, disappear over time but tend to reappear at different areas
pg775 |
|
|
|
Dad reports small, bluish lesions in the mouth with mucosal swelling on the lower lip and sublingual area.
|
Mucoceles and ranulas-intervention only if disruption of feeding
pg775 |
|
|
|
smooth, painless bluish-black areas of swelling found over an erupting tooth?
|
Eruption cyst-benign, no intervention
pg775 |
|
|
|
4yo female that just started school presents with painful vesicles to the tonsils and soft palate with fever, dysphagia and headache.
|
Herpangina stomatits-caused by coxsackie, viral culture gold standard, treatment is palliative
pg776 |
|
|
|
What is the treatment of stomatitis in kids
|
antipyretics, mixture of benadryl/maalox orally, swish and swallow. AVOID viscous lido due to risk of ingestion and assoc seizures.
pg776 |
|
|
|
What is the most common cause of hand, foot, and mouth disease
|
coxsackie A16
pg776 |
|
|
|
Hand, foot and mouth disease is primarily seen in what age and when?
|
infants and toddlers in the spring and summer months
pg776 |
|
|
|
What is the common presentation of hand, foot, and mouth disease
|
low grade fever and malaise for 2-3 days, then oral lesions followed by rash on hands, soles, and buttocks. enanthem and exanthem can occur simultaneously
pg776 |
|
|
|
What is the most common presentation of primary HSV infection in children
|
Acute herpetic gingivostomatits. incubation period is 2-12 days, mean of 4 days.
pg777 |
|
|
|
an infant is brought it with abrupt onset of high fever, irritability, decreased intake, with drooling and swollen erythematous, friable gingiva
|
Herpes gingivostomatitis
pg777 |
|
|
|
What is the treatment of herpes gingivostomatits
|
oral analgesics/antipyretics
severe disease - acyclovir 15mg/kg divided five times a day for 7 days. pg778 |
|
|
|
When evaluating a child with pharyngitis, does the presence of tonsillar exudate imply bacterial etiology?
|
NO-this often results in unnecessary abx treatment
pg778 |
|
|
|
8yo presents with fever, malaise, headache, exudative phayngitis and posterior cervical lymph node enlargement?
|
EBV-splenomegaly and hepatomegaly can also occur. mono spot not typically positive until after 1 week of symptoms.
|
|
|
|
What is the most commonly occurring form of acute bacterial pharyngitis for which abx therapy is indicated?
|
GABHS
Rare <2, usually 5-15yo in winter/early spring pg778 |
|
|
|
What is the Centor Criteria for GABHS pharyngitis diagnosis? (4)
|
Tonsillar exudate
Tender ant cervical lymphadenopathy absence of cough hx of fever pg779 table 117-4 |
|
|
|
How does the Centor criteria aid in you diagnosis and treatment of pharyngitis?
|
If two or more are present, preform a rapid antigen detection test (RADT) and/or culture
pg779 |
|
|
|
When two or more Centor criteria are present, but a RADT is negative what is recommended?
|
a confirmatory throat culture
pg779 |
|
|
|
Abx treatment of GABHS has been shown to shorten duration, prevent transmission, and prevent complications (3) and systemic illness (3) such as what
|
Complications-OM, sinusitis, PTA
systemic-Rheumatic fever, rheumatic heart disease, and poststrep glomerulonephritis pg779 |
|
|
|
What is the treatment of choice for children and adults with strep pharyngitis?
|
Pen V or amoxicillin
child-250mg BID x 10d Adolescent/adult-500mg BID x 10d pg779 table 117-5 |
|
|
|
What are alternative treatments for pen allergic pt with strep pharyngitis?
|
Erythromycin and first generation cephalosporins
pg779 |
|
|
|
after diagnosing Johnny with strep pharyngitis, Mom wants to know if the whole family should have prophylactic treated
|
Not recommended, risk is approximately 10%
pg779 |
|
|
|
What do you suspect in a 21yo male with exudative pharyngitis and urethritis?
|
Gonococcal infection - may also have proctitis or vaginitis. requires culture on Thayer-Martin medium.
pg779 |
|
|
|
A positive gonococcal infection in a prepubertal child is suspicious for what?
|
highly suspicious for child abuse and further investigation is warranted.
|
|
|
|
What should be considered in under- or unimmunized patients with symptoms of strep pharyngitis
|
C. diphtheriae-psuedomembrane formation can obstruct airway.
pg779 |
|
|
|
If C. diphtheriae is suspected, what is the treatment?
|
Pen and erythromycin are abc of choice along with equine diphtheria antitoxin.
pg779 |
|
|
|
What is the most common cause of Uvulitis in the unimmunized patient?
|
Hib
pg780 |
|
|
|
Noninfectious causes of uvulitis include trauma for instrumentation, vasculitis, allergic reaction, angioedema, and _______?
|
irritant inhalation
pg780 |
|
|
|
What are the most commonly injured teeth?
|
macillary central incisors
pg780 |
|
|
|
When does primary and secondary tooth eruption begin?
|
primary-6mo usually complete by 3yo
secondary-6yo pg780 |
|
|
|
Loosening of the tooth without displacement and sulcal bleeding is what?
|
Subluxation
primary tooth-no tx, secondary may need splinting f/u recommended for both as pulpal necrosis may occur pg780 |
|
|
|
Mom reports child fell, eating the sidewalk. concerned for a broken tooth. the tooths appears absent at first, with only the most distal portion visible. it is tender and not mobile?
|
Intrusion-driven apically into the socket, displacing alveolar bone. 90% re-erupt in 2-6mo.
pg781 |
|
|
|
The same clumsy kid comes back a week later for a different tooth. you see an elongated and mobile tooth?
|
Extrusion-displaced from socket. should be repositioned and splinted as soon as possible.
pg781 |
|
|
|
Avulsed primary teeth should not be replanted. Secondary require urgent reimplantation within what time?
|
85-90% survival within 5 min, and near-zero at 1 hour.
pg781 |
|
|
|
If an avulsed tooth cannot be reimplanted within 5 minutes it should be stored. What is a commonly available solution?
|
Milk-3rd in order of preference
pg781 |
|
|
|
What is the treatment for an 5mm laceration of the central tongue, not gaping and bleeding controlled?
|
None
pg781 |
|
|
|
When must lacerations of the mucosal surface be repaired? (2)
|
Full thickness and disruption of the vermillion border.
pg781 |
|
|
|
"willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom form pain and infection" defines what
|
dental neglect and is a form of child abuse., probably under reported by medical providers.
pg781 |
|
|
|
Gingivitis is seen mainly in the setting of poor hygiene, but can occur with infection, certain medications (like what) and even as a presentation of ____?
|
phenytoin (dilantin)
Leukemia pg782 |
|
|
|
A 22yo male presents with fever, halitosis, decreased appetite, and generalized malaise. Exam shows significant gingival edema and ulceration. What should you suspect?
|
Acute Necrotizing Ulcerative Gingivitis (ANUG)
pg782 |
|
|
|
Even 1mm of edema in the normal pediatric subglottis reduces its cross-sectional area by ____ resulting in significant airway obstruction in children.
|
50%
pg788 |
|
|
|
What is the ddx for stridor in a child <6mo old? (5)
|
laryngotracheomalacia
vocal cord paralysis subglottic stenosis hemangioma vascular ring/sling pg788 table119-1 |
|
|
|
What do you consider if there is marked variation in the pattern of stridor?
|
consider airway FB until proven otherwise.
pg788 |
|
|
|
what is the ddx for stridor in a child >6mo old? (5)
|
Croup
epiglottitis bacterial tracheitis FB aspiration Retropharyngeal abscess pg788 table 119-1 |
|
|
|
What is the most common cause of congenital stridor?
|
laryngomalacia, 60% of all neonatal laryngeal problems
pg788 |
|
|
|
Infant presents with feeding problems, stridor, horse voice, and cry changes?
|
unilateral vocal cord paralysis
bilateral more likely to have normal voice with dyspnea, cyanosis, and apneic episodes. pg788 |
|
|
|
You are evaluating a 2mo for "wheezing". You not persistent inspiratory stridor that mom says has been there for 'a while'. She was premature and spent 4 week intubated in the NICU.
|
Subglottic stenosis, can be congenital, MC cause is prolonged intubation in premature babies
pg788 |
|
|
|
Why is a thorough examination of the skin of an undressed infant an important aspect of the evaluation of stridor in the first 6 months of life?
|
hemangiomas-findings externally may be a clue to the presence of airway hemangioma. 80% are located above the clavicles.
pg788 |
|
|
|
What is the MC cause of stridor outside the neonatal period?
|
Croup-children 6mo to 3yo with a peak in second year of life.
pg789 |
|
|
|
What are the MC viruses detected in croup?
|
parainfluenza, RSV, human bocavirus, and rhinovirus
pg789 |
|
|
|
a 2yo old with 2 days of congestion, cough, low-grade fever, and rhinorrhea developed a horse voice and a harsh cough that was worst last night?
|
Croup-eval for tachypnea, stridor at rest, retractions, O2 desaturation and lethargy/agitation.
pg789 |
|
|
|
What is the typical duration of symptoms in Croup?
|
ranges from 3 to 7 days. most severe symptoms on day 3 or 4 and subsequently begin to improve.
pg789 |
|
|
|
How is the diagnosis of Croup made?
|
it is a clinical diagnosis. labs/xrays are unnecessary
pg789 |
|
|
|
If obtained, what is the radiographic finding on a PA CXR when evaluating for Croup?
|
subglottic narrowing "steeple sign"
absent in up to 50% of children with croup pg789 |
|
|
|
What is the mainstay of treatment for moderate to severe croup patients with marked retractions and stridor at rest?
|
Nebulized epinephrine
L-epi, 1:1000, 0.5ml/kg (max 5ml) Racemic, 2.25%, 0.05ml/kg/dose (max 0.5ml) pg790 |
|
|
|
Mild croup generally does not require epi, however all patients benefit from what?
|
a one-time dose of oral steroids
may crush pill and mix in juice or applesauce may give IV solution PO without dilution pg790 table119-4 |
|
|
|
You are treating a child for croup who is not PO tolerant. can you give IM dexamethasone in place of oral?
|
Yes IM is equally effective parenterally or orally
pg790 |
|
|
|
bed 17 is a 3yo with croup. He has received oral steroids and racemic epi. stridor and retractions have resolved. what is your disposition?
|
Nothing yet, he should be observed for 3 hours after nebulizer before considering discharge. 38% recurrence btwn 2nd and 3rd hour.
pg790 |
|
|
|
Why are Beta agonists avoided when signs of upper airway obstruction from edema are present?
|
vascular receptors cause vasodilation and may worsen edema and exacerbate obstruction
pg790 |
|
|
|
What are the criteria for discharge from ED in patients with Croup? (5)
|
3h since last dpi
nontoxic appearance PO tolerant caretaker able to recognize changes in condition and has transportation parents have a phone and no social concerns pg791 table 119-5 |
|
|
|
what is an additional treatment option in the treatment of severe, refractory croup?
|
Heliox 70/30 mix. the less dense helium replaces nitrogen decreasing airway resistance and improves flow.
pg791 |
|
|
|
Children with persistent stridor at rest, tachypnea, retractions, hypoxia, or those requiring ____ treatments of epi should be admitted.
|
two
pg791 |
|
|
|
In the post vaccine era, most cases of infectious epiglottitis are caused by what?
|
streptococcal and staphylococcal species
pg791 |
|
|
|
Nurse brings you a toxic appearing child with retractions and drooling. Mom reports abrupt onset of fever, sore throat, and drooling?
|
Epiglottitis-pt may be anxious, in a tripod or sniffing position to maintain airway.
|
|
|
|
although usually unnecessary, what could be seen on lateral neck films in suspected epiglottitis?
|
enlarge epiglottis protruding from anterior wall of hypophaynx and thickened aryepiglottic folds
"Thumb sign" pg791 |
|
|
|
What is the treatment for epiglottitis?
|
Keep in a comfortable upright position, provide O2 (blow by in scared kids), nebulized epi, consult ENT
Intubation should be done by the most skilled individual available, however preferred in OR. pg791 |
|
|
|
Mom brings in her 3yo daughter for sudden worsening of URI symptoms and high fever, cough. on exam you note a toxic appearing child with stridor.
|
bacterial tracheitis-uncommon infection causing life-threatening upper airway obstruction.
pg792 |
|
|
|
What is the most commonly isolated pathogen in bacterial tracheitis? what is the treatment?
|
S. aureus
initial choice ampicillin/sulbactam or combo of 3rd gen cephalosporin and clindamycin. pg792 |
|
|
|
How is bacterial tracheitis definitively diagnosed
|
bronchoscopy, no single clinical feature on radiograph.
pg792 |
|
|
|
Airway foreign body obstruction occurs MC in what age group?
|
btwn 1-3yo as a result of increasing mobility and oral exploration
MC objects food/toys: peanuts, hotdogs, grapes |
|
|
|
When should you consider FB aspiration in a young child?
|
any child with respiratory symptoms, regardless of the duration. many children present >24hr after aspiration
pg792 |
|
|
|
FB aspiration should be highly suspected when there is a history of what?
|
sudden coughing and choking. most predictive s/s. choking episode often not witnessed.
pg793 |
|
|
|
What is the classic dogma of laryngotracheal vs bronchial FB presentation
|
laryngotracheal-stridor and hoarseness
bronchial-unilateral wheezing and decreased breath sounds pg793 |
|
|
|
What is the most important factor in reducing mortality from an airway FB?
|
recognition of the child in acute distress. may present with severe immediate onset of stridor or arrest.
pg793 |
|
|
|
Where are most aspirated FB found in children?
|
80-90% in the bronchi
pg793 |
|
|
|
How are radiographs used in the evaluation of FB aspiration?
|
helpful to confirm, but should not be used to exclude. CXR are normal in >50% of tracheal FB and 25% of bronchial.
pg793 |
|
|
|
What percent of airway FB in children <3yo are radiolucent?
|
75%
pg793 |
|
|
|
This most common occurs in children who fall with a stick of other similar object in their mouth.
|
retropharyngeal abscess
pg793 |
|
|
|
A child presents with insidious onset of fever, neck pain, dysphagia, excessive drooling, and neck swelling. On exam you note bulging of the posterior oropharynx
|
retropharyngeal abscess
pg793 |
|
|
|
When is a lateral soft tissue neck suggestive of a retropharyngeal abscess/cellulitis?
|
retropharyngeal space at C2 is twice the diameter of vertebral body of >1/2 the width of C4 vertebral body. definitive dx by CT with IV contrast
pg794 |
|
|
|
What is the treatment for retropharyngeal abscess?
|
small localized abscesses abc therapy alone. all others get surgical I&D.
pg794 |
|
|
|
A 19yo c/o sore throat, fever, chills, trismus, and voice changes.
|
PTA - most unilateral and mc in adolescents and young adults
pg795 |
|
|
|
a 16yo c/o 'the worst sore throat' of their life with left ear pain. You are thinking PTA, what are you looking for on exam?
|
bulging of the affected tonsil and deviation of the uvula away form abscess.
pg795 |
|
|
|
What is the management of a PTA?
|
most cases get prompt aspiration or I&D. In nontoxic-appearing teens with good f/u a trial of abx may be the best choice.
|
|
|
|
How do you confirm/differentiate the dx of PTA from cellulitis?
|
CT with IV contrast
pg795 |
|
|
|
What are the potential complications of needle aspiration and I&D of a PTA?
|
hemorrhage, puncture of the carotid artery, and aspiration of purulent material.
pg795 |
|
|
|
Rapidly expanding infection of the submandibular space extending from the floor of the mouth to the hyoid bone?
|
Ludwig angina - spreads superiorly and posteriorly.
pg796 |
|
|
|
What is the MC source for Ludwig angina?
|
85% arise from an odontigenic source, often from the spread of a periodical abscesses of mandibular molars.
pg796 |
|
|
|
What is the treatment of Ludwig angina?
|
abx and oral surgery to remove the dental abscess that is the source of the infection.
pg796 |
|
|
|
a 3yo is brought in after falling with a pencil in his mouth. he is drooling and bleeding from the mouth. What is an important question to ask the parents?
|
Was the FB removed intact or if part of the object may have broken off.
pg796 |
|
|
|
Complications of oropharyngeal trauma are entrance of free air into the neck or chest and subsequent retropharyngeal infection. a more severe complication is what?
|
Carotid artery injury from penetrating and blunt impact forces.
pg796 |
|
|
|
In the presence of hyperinflation above residual capacity, elastic recoil must be overcome before a breath can be initiated. this is referred to as what
|
Auto-positive end-experiratory pressure
pg797 |
|
|
|
an 8yo with c/o SOB when walking, is speaking in full sentences, moderate end-expiratory wheezing, O2 sat 96%, no accessory muscle use. asthma exacerbation severity?
|
Mild - can lie down, may be agitated, increased RR, HR<100,
pg798 table 120-2 |
|
|
|
Mom reports her 7yo has breathing trouble. first noticed while child was watching TV, child agitated and increased if you lay the bed down, only speaks in short phrases, O2 93%, retractions, wheezing throughout expiration. Asthma exacerbation severity?
|
Moderate - infant may have softer/shorter cry or difficulty feeding, HR 100-200,
pg798 table120-2 |
|
|
|
the 6yo in bed 19 appears agitated and is sitting upright, O2 sat 88%, RR 35 with accessory muscle use, can only answer questions one word at a time. Asthma exacerbation severity?
|
Severe - infant stops feeding, HR > 120
pg798 table 120-2 |
|
|
|
infants and children with asthma/bronchiolitis have mild hypoxemia (>92%) that readily correct with O2 supplementation. More severe hypoxemia is concerning for what? (3)
|
alveolar disease (pneumonia), pnuemothorax, true pulmonary shunt. Diaphoresis, confusion, or drowsiness are ominous signs.
pg798 |
|
|
|
What is more important than the initial exam findings in the evaluation of a child with wheezing?
|
response to bronchodilators and other treatments.
pg798 |
|
|
|
DDX: wheezing present from birth, feeding-related cough, gagging or emesis. (2)
|
Reflux or tracheoesophageal fistula.
what ancillary testing is next? |
pH probe
Barium swallow pg799 table 120-3 |
|
|
DDX: wheezing present from birth, multiple lower respiratory tract infections, failure to thrive (3)
|
Cystic fibrosis
Ciliary dyskinesia Immunodeficiency what next? |
Sweat chloride test
ciliary biopsy Immunoglobulin assays pg799 table 120-3 |
|
|
DDX: wheezing, diffuse rales; tachycardia; hepatomegaly; cardiac murmur (2)
|
congenital hear disease with left-to-right shunt and CHF
myocarditis What testing next? |
CXR, ECG, Echo
pg799 table 120-3 |
|
|
DDX: wheezing associated with stridor; positional changes with neck flexion, extension, or rotation (3)
|
vascular ring or other great vessel malformation; airway polyp or hemangioma
what testing next? |
CXR; CT angio; barium swallow; bronchoscopy
pg799 table 120-3 |
|
|
DDX: abrupt-onset stridor and/or wheezing; hx of choking episode
|
Foreign-body aspiration
vocal cord dysfunction what testing next? |
rt and left lateral decubitus CXRs
Bronchoscopy flexible fiberoptic laryngoscopy pg799 table 120-3 |
|
|
DDX: stridor and/or wheezing that changes with position, or is exacerbated during feeding or URI
|
tracheomalacia
Laryngomalacia What next? |
Observation
Bronchoscopy pg799 table 120-3 |
|
|
DDX: Wheezing, URI symptoms, nasal flaring, season outbreaks
|
bronchiolitis
What next? |
viral antigen testing
pg799 table 120-3 |
|
|
How long do bronchiolitis symptoms usually last?
|
on average 7 to 14 days and are often worst in the initial 3 to 5 days of illness
pg799 |
|
|
|
What are considered normal respiratory rates in otherwise healthy newborns, 6mo, and 1yo?
|
50, 40, 30 breaths/min
pg800 |
|
|
|
rhinorrhea, tachypnea, and wheezing in a child <2yo
|
Bronchiolitis
pg800 |
|
|
|
What ancillary tests are routinely ordered for the evaluation of bronchiolitis?
|
None unless other diagnoses need to be excluded
pg800 |
|
|
|
The american academy of pediatrics recommends maintaining an O2 sat of what
|
>90%
pg800 |
|
|
|
what are the indications to use bronchodilators in the treatment of bronchiolitis?
|
None - no consistent evidence either alpha or beta bronchodilators are of benefit
pg800 |
|
|
|
What are the risk factors for severe disease and apnea in infants with bronchiolitis? (6)
|
Prematurity(<37wk); age<12wk; witnessed episode of apnea; underlying cardiopulmonary disease; chronic lung disease; Immunodeficiency
pg799 table 120-4 |
|
|
|
What is the treatment for Bronchiloitis without respiratory distress (O2>95%) and no risk factors for admission? (3)
|
Observe during feeding if concerned for severe disease; discharge with saline drops and suctioning; abx if evidence of UTI or OM.
pg800 table 120-6 |
|
|
|
What should be considered when treating an ill-appearing, dehydrated, apneic (O2<95%) infant for bronchiolitis?
|
racemic epi; most need admission otherwise observation for 4 hours before discharge
pg800 table 120-6 |
|
|
|
What is the normal PaCO2 in patients aged 7 to 19
|
37mmHg
pg802 |
|
|
|
ETco2 should be lower than normal in children with asthma exacerbation. Levels of ETco2 are normally ______lower than capillary or arterial Paco2.
|
3 to 5mmHg
pg802 |
|
|
|
In both children and adults a Paco2 of _____may be a sign of impending ventilatory failure.
|
40-42mmHg
pg802 |
|
|
|
wheezing is pathognomonic for airway obstruction and typically occurs more during expiration than during inspiration. what is an ominous sign of severely compromised ventilation
|
quiet chest - indicates airflow insufficient to generate wheezing.
pg802 |
|
|
|
What are the indications for a CXR in the child with acute asthma? (4)
|
1)unexplained fever
2)r/o pneumo 3)possible FB or CHF 4)localized rales/dullness that does not resolve with bronchodilator pg 803 |
|
|
|
In addition to albuterol/ipatropium, most pt presenting to the ED for asthma exacerbation should be treated immediately with what?
|
systemic steroids
Prednisone 1-2mg/kg dexamethasone 0.6 mg/km PO or IM pg805 |
|
|
|
pt treated for asthma exacerbation should be discharged with what else?
|
3 to 5 day course of steroids
pg805 |
|
|
|
Mg inhibits smooth muscle contraction through competition of the calcium channel. What dose is favored?
|
75mg/kg, max 2.5grams
pg807 |
|
|
|
Induction agent for pending respiratory failure due to asthma?
|
ketamine 2mg/kg bolus then 2-3mg/kg/h
may prevent need to intubate pg807 |
|
|
|
If aminphylline (theophylline) is used, what is the goal of tx
|
serum theophylline of 10 to 14mg/dL
pg807 |
|
|
|
T/F
1/3 of pediatric deaths from asthma are in children who previously had only mild asthma |
TRUE
pg807 |
|
|
|
Reasonable initial applied BiPAP pressures for severe asthma are an IPAP of ____ and EPAP of ____?
|
IPAP 12, range of 12-18
EPAP 6, ranges of 6-12 |
|
|
|
Acute gastroenteritis is typically defined by what
|
three or more diarrheal stools in 24 -hour period
pg831 |
|
|
|
if a known outbreak of hemolytic uremic syndrome or a pos culture for E. coli O157:H7 further testing should be preformed to r/o evidence of what? (3)
|
renal failure, thrombocytopenia, and hemolytic anemia
pg832 |
|
|
|
Why does a perforated appendix cause diarrhea
|
inflammation irritates the colon
pg832 |
|
|
|
What are the high risk factors warranting stool cultures in children with diarrhea? (6)
|
>10 stools in 24 hours; fever; blood/mucus; abdominal pain; travel to high risk country; older age
pg834 |
|
|
|
electrolyte abnormalities in children with diarrhea are usually minor, however measurement of this is essential in all infants and young children
|
serum glucose - prevalence of hypoglycemia as high as 9% in pediatric gastroenteritis
pg834/835 |
|
|
|
the WHO recommends ORS with a sodium concentration of what?
|
75mmol/L - tea, juice, or sports drinks are deficient in sodium with excessive sugar resulting in amplified fluid loss
pg835 |
|
|
|
when is IV rehydration recommended in children with dehydration?
|
severe dehydration, hemodynamic compromise, or AMS precludes oral fluids
pg835 |
|
|
|
How do you prescribe ORS to children for dehydration?
|
50 to 100ml/kg, plus additional to compensate for ongoing loss (approx 10ml/kg per stool and 2ml/kg per emesis)
over 4 hours, offer 5ml q2-5min pg835 |
|
|
|
What is a general rule for ORS administration?
|
1 ounce (30ml) per kg of body weight per hour
do not limit breastfeeding during any phase of ORT pg835 |
|
|
|
What may be used as an adjust to ORT in children with persistent vomiting?
|
Ondansetron, a 5HT (serotonin) agonist
0.15mg/kg/dose IV/PO pg836 |
|
|
|
dopamine receptor agonists (such as promethazine, prochlorperazine, metoclopramide, droperidol) should not be used in children due to what side effects?
|
respiratory depression and extrapyramidal reactions. in addition they lack evidence of efficacy
pg836 |
|
|
|
T/F
while providing ORS to a dehydrated child, you should withhold feedings for 5 hours. |
FALSE
do not withhold feedings > 4hr in a dehydrated child or any length in a child not dehydrated pg836 |
|
|
|
T/F
Most young children can continue to receive lactose-containing milk or formula with diarrhea and dehydration |
TRUE
may increase duration, but unlikely to be significant pg837 |
|
|
|
antimotility agents are contraindicated in children due to what serious adverse events? (3)
|
paralytic ileus, lethargy, death
pg837 |
|
|
|
What is Loperamide associated with when used in the setting of enterohemorrhagic E. coli infection
|
hemolytic uremic syndrome
pg837 |
|
|
|
Bismuth has a modest effect on reducing severity of diarrhea, but can elevate levels of what?
|
salicylates - labeled for use in adults and children 12 and older.
pg837 |
|
|
|
What 2 probiotics have most constantly shown benefit in meta-analyses?
|
Lactobacillus GG
Saccharomyces boulardii pg837 |
|
|
|
What is the most common cause of inflammatory diarrhea with mucus and high fever?
|
Shigella sp, Campylobacter and S. enterica
pg837 |
|
|
|
Children with watery diarrhea should not receive empiric abx unless exposed to what?
|
cholera
pg837 |
|
|
|
Why is it recommended that children with E. coli O157:H7 should not receive antibiotics?
|
increased risk of hemolytic uremic syndrome
|
|
|
|
Children with a cow's milk allergy usually outgrow their sensitivity by what age?
|
3
pg838 |
|
|
|
what abx are most frequently implicated in C. difficult diarrhea
|
clindamycin, cephalosporins, and penacillins
pg838 |
|
|
|
indications for treatment of C. difficile include positive assays for toxin and what?
|
at least one of the following: need to continue abx, colitis, severe diarrhea, persistent diarrhea despite discontinuation of abx,
pg838 |
|
|
|
What is the abx of choice for the treatment of C. difficile?
|
Metronidazole: less expensive than vancomycin and avoids promoting vanc-resistant enterococci
pg838 |
|
|
|
What is the pathognomonic electrolyte abnormality of pyloric stenosis?
|
hyponatremic, hypokalemic, hypochloremic metabolic alkalosis.
dx confirmed by US |
|
|
|
Intussusception is the leading cause of obstruction in infants occurring at what age?
|
between 3 and 12 months
What is the location |
ileocolic and the lead point is usually hypertrophied Peyer Patch
|
|
|
Although malrotation can present at any age, nearly half present when?
|
the first week of life, and 2/3 within the first month
pg839 |
|
|
|
What parasites are most likely to cause diarrhea?
|
Cryptosporidium and Giardia
pg839 |
|
|
|
In nonverbal children, a history of high [>40C (104F)] or prolonged fever appears to be most predictive of what?
|
UTI
pg854 |
|
|
|
Although the presence of another source of fever lowers the risk of UTI, it can coexist with other common viral syndromes such as ?
|
RSV bronchiolitis
pg855 |
|
|
|
In infants and young children, the only cardinal feature of UTI is what?
|
a febrile illness without other definitive source
pg855 |
|
|
|
What is the gold standard for obtaining urine for urinalysis and culture?
|
suprapubic aspiration
pg855 |
|
|
|
T/F
Most gram-positive bacteria will reduce nitrate if the urine has been in the bladder long enough |
FALSE
Enterobacteria generally reduce nitrate, gram-pos do not; therefore nitrite has reduced sensitivity for detection of UTI pg855 |
|
|
|
T/F
Regardless of results from dipstick or microscopic analysis, send all urine collected to evaluate for UTI to the lab for culture. |
TRUE
pg856 |
|
|
|
What is the treatment for first time UTI in <1mo old?
|
admit for iv abx for 3-5 days followed by 14d PO abx
pg857 table 126-5 |
|
|
|
What is the treatment for first time UTI in >1mo to 2y old?
|
if toxic admit;
nontoxic, not vomiting, hydrated; ceftriaxone 50mg/kg in ED; PO abx for 14d. f/u with peds in 24h pg857 table 126-5 |
|
|
|
What is the treatment for first UTI in children >2 to 13yo?
|
based on local resistance patterns, PO abx for 7d, f/u with peds in 2-3d
pg857 table 126-5 |
|
|
|
What is the treatment for UTI in adolescent girls (>13yo)
|
option to treat for 3d
pg857 table 126-5 |
|
|
|
The presence of what bacteria increases the likelihood of an underlying urinary tract abnormality?
|
Enterococcus faecalis (gram-pos); if suspected due to prior infection of gram stain pos, add ampicillian/amoxicillin or vanc to other therapy
pg857 |
|
|
|
The presence of LE with a negative urine culture in a symptomatic adolescent should suggest what?
|
sexually transmitted disease such as chlamydia or gonorrhea
pg858 |
|
|
|
What is the ddx for acute HA; single episode without hx of previous events? (5)
|
URI; sinusitis; first migraine; medication use; trauma
pg 881 table 130-2 |
|
|
|
What is the ddx for acute recurrent HA separated by symptom-free intervals
|
migraine
pg 881 table 130-2 |
|
|
|
what is the ddx for chronic progressive HA gradually increasing in frequency and severity (3)
|
space occupying lesion, hematoma, pseudotumor cerebri
pg 881 table 130-2 |
|
|
|
What is the ddx for chronic nonprogressive HA (chronic daily) pattern is frequent or constant (2)
|
tension or cluster
pg 881 table 130-2 |
|
|
|
HA with abnormal neuro exam; <6mo duration, sleep-related, absence of visual symptoms, no FMHx of migraine, vomiting and confusion suggest what?
|
space occupying lesion
pg881 |
|
|
|
What are among the most common causes of HA in children?
|
viral illness and fever (possibly from vasodilation); frequently frontal or temporal
pg881 |
|
|
|
T/F
HA are among the most commonly reported symptoms in toxic exposures such as carbon monoxide poisoning. |
True
pg881 |
|
|
|
abrupt occurrence of severe HA associated with abnormal neuro (AMS, ataxia, nuchal rigidity, papilledema, or hemiparesis) are due to what?
|
brain tumor or intracranial hemorrhage
pg881 |
|
|
|
Migraine HA in children typically start relatively abruptly, intensify over several minutes, and then reach full intensity in what time?
|
about a hour; unlike adults often begin in late afternoon
pg881 |
|
|
|
T/F
an inability to describe the pain or a description of the HA as constrictive indicates a greater likelihood of a more serious cause. |
True; pulsating quality more frequently assoc with benign HA
pg881 |
|
|
|
What is status migrainosus?
|
a migraine that lasts >72h
pg882 |
|
|
|
Headache with effortless vomiting but no GI complaint is characteristic of what?
|
elevated intracranial pressure
pg882 |
|
|
|
headaches with irreversible and progressive defects in visual acuity and diplopia are suggestive of what?
|
Idiopathic itracranial hypertension (pseudotumor cerebri)
pg882 |
|
|
|
T/F
Secondary HA require treatment of the underlying condition. Primary HA should be treated with narcotics |
FALSE
narcotics can change pain-modulatory system in the brainstem often leading to more intense pain pg883 |
|
|
|
Promethazine should not be used in children <2yo because of the risk of what?
|
fatal respiratory depression
pg884 |
|
|
|
The A,V,P,U values correspond to glasgow coma scale of what respectively
|
A=15, V=13, P=8, U=3
|
|
|
|
What is the ddx for AMS?
|
AEIOU TIPS; Alcohol, Encephalopathy, Insulin, Opiates, Uremia, Trauma, Infection, Poisoning, Seizure
|
|
|
|
Pediatric alcohol intoxication can occur from what (3)
|
methanol, ethanol, and isopropanal
Hypoglycemia may coexist pg886 |
|
|
|
hypertensive encephalopathy may occur in children at diastolic pressures of ?
|
100 to 110
pg886 |
|
|
|
mom brings in her 4yo girl for AMS. she is afebrile, anicteric, recent hx of URI that mom treated with ASA
|
Reye syndrome
pg886 |
|
|
|
You are one of the kids on the unicef commercial with with altered mental status, ataxia, and ocular palsies
|
Wernicke encephalopathy - children with nutritional deficiencies, malignancies, and immunodeficiencies
pg886 |
|
|
|
a child with n/v, ab pain, weakness, malaise, and AMS. He is hypotensive, depressed Na and glucose, increased K with variable increase in calcium. What do you suspect
|
Addison disease
may also have hyper pigmentation pg886 |
|
|
|
infant with acute salt-losing, volume depleted hypotensive crisis and hypoglycemia. ambiguous genitalia
|
Congenital adrenal hyperplasia
pg886 |
|
|
|
hyponatremic children become symptomatic at plasma levels of approx?
|
120mEq/L
pg886 |
|
|
|
Infants and children are prone to develop _______ with fasting, especially with infections in early infancy
|
ketotic hypoglycemia
pg886 |
|
|
|
What may be the initial and predominant symptom of intussespetion?
|
Altered mental status
pg887 |
|
|
|
Children who have ingested opiates may present with miosis, absent bowel sound, and lethargy. What are common opiates that my be present in the household?
|
Dextromethorphan, diphenoxylate plus atropine (lomotil) and loperaminde.
Suspect abuse and neglect pg887 |
|
|
|
In children with chronic renal failure, neurologic dysfunction may develop secondary to what? (3)
|
hypertension
stroke metabolic derangements pg887 |
|
|
|
What is the most common cause of acute renal failure in children?
|
Hemolytic-uremic syndrome
Oliguria, microangiopathic hemolytic anemia, and thrombocytopenia with purpura pg887 |
|
|
|
Post-traumatic loss of consciousness followed by a lucid interval and then rapid progression of decreasing consciousness
|
acute epidural hematoma
can also present with gradual loss of consciousness and ipsilateral pupillary dilatation pg887 |
|
|
|
T/F
Children with blunt head trauma are more likely than adults to develop diffuse cerebral swelling, ICP, and AMS without extra or intracerebral collections of blood |
TRUE
pg887 |
|
|
|
Fever, malaise, anorexia, and soar mouth. Oral lesions appear 1 to 2 days later and cutaneous lesions shortly thereafter
|
hand, foot and mouth disease.
Lesions heal in 7 to 10 days pg910 |
|
|
|
fever, mouth pain, oral whitish ulcers located on the soft palate and posterior pharynx without accompanying skin lesions
|
herpangina
pg911 |
|
|
|
erythematous maculopapular rash behind the ears and at the hairline of the forehead, blanches with pressure. General malaise, systemic toxicity, fever, conjunctivitis, photophobia and cough
|
measles
rash progresses to confluence, especially on the face exanthem develops approx 14 days post exposure |
|
|
|
white to bluish-white, 1mm discrete spots on a red base involving the buccal mucosa?
|
koplick spots - pathognomonic for measles
|
|
|
|
prodrome of fever, HA, sore throat followed by irregular pink macules/papules on the face, spreading to the neck/trunk/arms.
|
Rubella "German Measles"
pg912 |
|
|
|
Lymphadenopathy is a clinical manifestation of rubella, with characteristic enlargement of which nodes?
|
suboccipital and posterior auricular nodes
pg912 |
|
|
|
acute fever with a fiery red rash on the cheeks, most intense below the eyes, extending over the cheeks similar to butterfly wings
|
Erythema infectiosum "fifth disease"
caused by human parvovirus B19 slapped-cheek appearance sparing the eyelids and chin pg912 |
|
|
|
a distinctive aspect of this rash is that it fades with central clearing, giving a reticulated or lacy appearance.
|
Erythema Infectiosum (Fifth disease)
human parvo B19; age 5-15; palms and soles are rarely affected pg912 |
|
|
|
Varicella most frequently occurs in children of what age?
|
<10yo but may occur at any age
generally in late winter and early spring pg913 |
|
|
|
What are the possible complications of varicella? (4)
|
encephalitis, PNA, hepatitis, bacterial super infection of the ruptured vesicles
pg913 |
|
|
|
febrile period of 3 to 5 days, defervescence, then a rash appears for 1 or 2 days. maculopapular on neck, trunk, buttocks; blanch with pressure
no mucosal involvement |
Roseola infantum
pg914 |
|
|
|
Impetigo is caused by which organisms
|
S. aureus or B-hemolytic strep
pg915 |
|
|
|
separation of the skin when pressure is applied?
|
nikolsky sign present with scalded skin syndrome
pg916 |
|
|
|
Linear petechial eruptions often present in the antecubital and axillary folds
|
Pastia lines, seen in scarlet fever
strawberry tongue, sandpaper rash, caused by GABHS pg917 |
|
|
|
cellulitis and lymphangitis of the skin caused by GABHS. most common on face
|
Erysipelas "St. Anthony fire"
|
|
|
|
What is the treatment for scabies
|
permethrin cream applied from the neck down and left for 8 to 12 hours. if severe a single dose of ivermectin
tx all family members pg918 |
|
|
|
T/F
Lindane shampoo should be used in young children and pregnant women to treat for lice |
FALSE - causes neurotoxicity
use permethrin 1% lotion pg919 |
|
|
|
Fever for at least 5 days duration and the presence of four other findings; bilateral nonexudative conjunctivitis, cervical lymphadenopathy, erythema of lips/oral mucosa, various skin changes and rash
|
Criteria for classic Kawasaki disease
KD peaks at 18-24mo, rare <4mo or >5yo pg922 |
|
|
|
Incomplete KD is defined by fever and at least two of the clinical symptoms of classic disease but with what else?
|
supportive labs - CRP>3, ESR>40
pg923 |
|
|
|
non-blanching palpable purpura, renal disease, abdominal pain, and polyarthralgias
|
Henoch-Scholein purpura - MC vasculitis of childhood
strep and antistreptolysin O titers elevated 50% of pt pg923 |
|
|
|
T/F
LOC occurs with the onset of mvmnt in seizures, but LOC precedes mvmnt in most cases of true syncope |
TRUE
pg964 |
|
|
|
Neurally mediated syncope is the MC type in children, usually preceded by what?
|
sensation of warmth, nausea, light-head, visual grayout or tunnel vision
pg965 |
|
|
|
T/F
Breath holding spells are not a variant of neurally mediated syncope. |
FALSE
pg965 |
|
|
|
How does syncope and sudden death occur after pacemaker placement to treat sick sinus syndrome
|
pacemaker prevents bradycardia but not tachycardia
pg966 |
|
|
|
What is the serum sodium concentration in isonatremic dehydration?
|
130 to 150 mEq/L
Most common form pg972 |
|
|
|
fluid resuscitation in moderate and sever dehydration?
|
20ml/kg bolus over 5 to 10min, repeat until hemodynamics stabilize
give a min of 60ml/kg or more in first hour unless CI based on pt disease pg973 |
|
|
|
What are the daily requirements for sodium and potassium
|
Na 2-3 mEq/kg/d
K 2 mEq/kg/d pg974 |
|
|
|
What is the treatment for symptomatic hyponatremia
|
4mL/kg of 3% NaCl over 30-60 min; correct to Na of 120
pg974 table 142-6 |
|
|
|
What is the most common cause of hypotonic fluid losses in children causing hypernatremic dehydration
|
Diarrhea
pg975 |
|
|
|
What are the treatment goals for hypernatremia?
|
restore volume and decrease sodium at a rate of 0.5 to 1 mEq/L/h
pg975 |
|
|
|
what is the rate for IV replenishment of K
|
0.2 to 0.3 mEq/kg/h
pg975 |
|
|
|
What is the treatment of choice for symptomatic hypocalcemia?
|
calcium gluconate 10%; 100mg/kg at a rate not to exceed 100mg/min with continuous ECG monitoring
pg976 |
|
|
|
prolonged seizure that cannot be controlled with two or more standard doses of treatment
|
Refractory status epilepticus
pg873 |
|
|
|
pt suddenly lacks muscle tone and drops to the ground
|
Atonic seizure
pg873 |
|
|
|
prolonged seizures or recurrent seizures lasting >5 min with out pt regaining consciousness
|
status epilepticus
pg873 |
|
|
|
What is the most common condition that may be mistaken for seizure?
|
syncope
Brief LOC, no postictal period pg873 |
|
|
|
Seizure and fever can be associated with CNS infection. However more commonly it is what
|
simple febrile seizure
fever lowers seizure threshold pg873 |
|
|
|
Focal deficit of unknown etiology that can last up to 36 hours after a seizure
|
Todd paralysis
pg874 |
|
|
|
When treating seizures, initial benzo treatment should be limited to how many doses
|
2
pg874 |
|
|
|
If a seizure persists for another 5 min after two doses of a benzo, what is the next step?
|
fosphenytoin or phenobarbital are preferred second line agents
|
|
|
|
what is preferred for children with phenytoin allergy, febrile illness, and are <2yo
|
phenobarbital
pg875 |
|
|
|
What are the SE of phenobarbital?
|
cardiorespiratory depression and sedation with may be amplified by benzos
pg875 |
|
|
|
What is the third line treatment of seizures
|
valproic acid, levetiracetam, or propofol
pg875 |
|
|
|
Why should valproic acid be used with caution in children with metabolic disease?
|
in rare cases may cause hepatic failure
pg875 |
|
|
|
a generalized tonic-clonic seizure lasting <15min with a fever >38C in a child 6mo to 5yo that occurs only once in a 24hr period
|
simple febrile seizure
pg878 |
|
|
|
Are LP and imaging mandatory for a simple febrile seizure?
|
no
pg878 |
|
|
|
seizure with a fever that last >15min, recur within 24hr, are focal, without any signs of serious infection
|
Complex febrile seizure
age <6mo or >5yo pg878 |
|
|
|
clinical presentation of neonatal seizure
|
lip smacking, eye deviation, rhythmic blinking, "bicycling" movements, and an ALTE
pg879 |
|
|
|
two or more seizures without acute provocation (e.g., fever or trauma)
|
epilepsy
pg879 |
|
|
|
T/F
"impact seizures" (occur within minutes of head trauma) are associated with severe head injury |
False
pg879 |
|
|
|
Children with fever and seizures lasting____ have a higher incidence (15% to 18%) of bacterial meningitis than children with simple febrile seizure
|
30min
simple = 0.4 to 1.2 pg878 |
|
