Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
574 Cards in this Set
- Front
- Back
|
What is the most common cause of neonatal jaundice? What is the second most common?
|
-physiologic jaundice of the newborn
-breast milk jaundice |
|
|
What is the pathway for bilirubin formation?
|
heme is broken down to biliverdin and unconjugated bilirubin, the bilirubin bind to albumin and then is conjugated in the liver
|
|
|
What is the typical presentation of physiologic jaundice?
|
-normal bilirubin at birth
-increases to a peak of 6mg/dL on the 3rd day of life -decreases to normal within 2 weeks of life This jaundice is caused by hemolysis of fetal hemoglobin |
|
|
How does breast mild jaundice present?
|
-same gradual increase as physiologic jaundice
-levels peak at 10d to 3 weeks of life |
|
|
What is kernicterus?
|
Yellow staining in areas of the brain including the basal ganglia
|
|
|
What are therapies for hyperbilirubinemia?
|
-phototherapy
-exchange transfusion |
|
|
Which type of hyperbilirubinemia is always abnormal?
|
Conjugated (direct) hyperbilirubinemia
Defined as DB >20% total or >34umol/L |
|
|
WHat tests should be ordered in suspected pathologic jaundice?
|
-cbc
-peripheral smear -Coombs test -glucose -electrolytes -urine for reducing substances -serum ammonia |
|
|
What are the TORCHS infections?
|
-toxoplasmosis
-other infections -rubella -cytomegalovirus -herpes -syphillis (Other: coxsacki, parvovirus, HIV, HBVm Varicella) |
|
|
What is the general guideline for treatment of hyperbilirubinemia?
|
-18-20mg/dL
|
|
|
What does conjugated hyperbilirubinemia usually indicate?
|
Hepatobiliary disease
|
|
|
What is the pathophysiology of electrolyte derangements in hypertrophic pyloric stenosis?
|
Gastric outlet obstruction results in vomiting with losses of H+ and Cl-, kidney retains H+ in exchange for K+, therefore we have a hypochloremic, hypokalemic metabolic alkalosis
|
|
|
What is the diagnostic modality of choice for hypertrophic pyloric stenosis?
|
Ultrasonography
|
|
|
What are major considerations in the differential diagnosis of hypertrophic pyloric stenosis?
|
-gastrointestinal reflux (occurs earlier in life and is more constant)
-malrotation (more often bilious voimiting) |
|
|
What is the fluid resuscitation of hypertrophic pyloric stenosis?
|
20cc/kg bolus until no shock. Then D51/2 NS at 1.5-2.0 x maintenance (4:2:1) with K+ supplementation
|
|
|
What is the hallmark presentation of malrotation with midgut volvulus?
|
bilious emesis
|
|
|
What are the main anatomical derangements in malrotation with volvulus?
|
Distal duodenal obstruction
compression of the SMA |
|
|
What is the double bubble sign and what does it indicate?
|
-A finding on GI series - dilated stomach and obstructed proximal duodenum
-Suggestive of either duodenal atresia or malrotation with midgut volvulus |
|
|
What is the diagnostic procedure of choice for midgut volvulus?
|
Upper GI series
|
|
|
What is the differential diagnosis of malrotation?
|
GE reflux
Hypertrophic pyloric stenosis NEC ( would have diffusely dilated loops of small bowel on X-ray +/- pneumatosis intestinal is |
|
|
What is the most common RF for NEC?
|
Prematurity
|
|
|
What antibiotics do you give to ill appearing infants with midgut volvulus?
|
Ampi/genta and clinda or flagyl
|
|
|
What is the cause of GE reflux?
|
An incompetent lower esophageal sphincter
|
|
|
What is Sandifers syndrome?
|
Disorder associated with GE reflux -> opisthotonic movements (extension) with shrill guttural cry and brief episodes of apnea
|
|
|
What are conservative measures for the treatment of GE reflux?
|
Smaller feedings
frequent burpings thickening of formula with cereal semi-upright position for 45min - 1 hour after feeds |
|
|
When should infants with GE reflux be referred to GI?
|
Weight loss
|
|
|
What are options for medical management of GERD?
|
-ranidtidine (decreased gastric acid secretion)
-metoclopromide (decreased LES tone, decreased PS tone and increased motility) |
|
|
What is the common age for presentation of intussusception?
|
5mo->12mo
|
|
|
What typically causes intussusception in children <5? >5?
|
In <5year olds it is usually Peyer's patchiest (secondary to recent viral infections)
In >5years it is often due to an underlying lesion (HSP, Meckels, lymphoma, celiac) |
|
|
WHat is the classic triad of intussusception?
|
-abdo pain
-vomiting -bloody stools |
|
|
What is Dance's sign?
|
-sausage like mass in the RUQ
-empty space in the RLQ representing movement of the cecum out of its normal position |
|
|
What are X-ray findings of intussusception?
|
-mass/mass effect
-obstruction -target sign -meniscus (crescent) sign -free air |
|
|
What is Hirschsprungs ?
|
Congenital aganglionosis of the colon
|
|
|
What are pathologic causes of constipation?
|
-Hirschsprung's
-CF -Infantile botulism -hypothyroidism |
|
|
What are the Meckel's rules of 2
|
2cm wide
2cm long within 2 feet of the ileocecal valve 2% of the population 2% affected its become symptomatic -1/2 symptomatic by the age of 2 |
|
|
What is the typical presentation of Meckel's?
|
Massive painless rectal bleeding
|
|
|
What is the diagnostic modality of choice for MD?
|
-technetium scan (Meckel's scan)
|
|
|
What causes a false positive hemoccult test?
|
-red meat
-iodine |
|
|
What is the Apt test?
|
A test to determine if bloody stool is from maternal or fetal blood
|
|
|
What causes black stool that is hemoccult +?
|
Bismuth
iron spinach |
|
|
What is HSP?
|
An abdominal vasculitis commonly associated with abdo pain and rash (it is a hypersensitivity vasculitis)
|
|
|
What are the classic clinical features of HSP?
|
-rash
-abdo pain -microscopic hematuria -arthragia |
|
|
What are the characteristics of the HSP rash?
|
Palpable, purpura on the LE and buttocks
|
|
|
What must be ruled out in a child with HSP and worrisome abdo pain? What test is used?
|
Ileocecal intussusception, CT (this diagnosis is not easily detectable on US)
|
|
|
What is the main Ddx for HSP?
|
Meningococcemia
|
|
|
Should HSP be managed with steroids?
|
It is controversial and they should probably only be givent to those with severe disease
|
|
|
What are the main differences between Ulcerative colitis and Crohns disease?
|
UC - mucosal/submucosal inflammation of the rectum and distal colon
Crohns - transmural and may involve any portion of the intestinal tract |
|
|
What are extra intestinal manifestations of IBD?
|
-fever
-anemia -oral ulceration -erythema nodosum -pyoderma gangrenosum -uveitis -liver dysfunction -FTT |
|
|
What is the most feared complication of IBD and how does it present?
|
Toxic megacolon
It presents with abdo pain, fever and bloody diarrhea |
|
|
What is the most common GI FB in children? in adults?
|
Child - coins
Adult - food |
|
|
What are the normal physiological narrowing points of the esophagus?
|
cricopharyngeus muscle
aortic arch/trachal bifurcation LES |
|
|
What is the most common side of GI FP perforation?
|
ileocecal valve
|
|
|
What is the management of esophageal FB?
|
Removal within 24 hours to decrease the risk of aspiration and esophageal erosion
|
|
|
Should button batteries in the stomach be removed?
|
NO, unless they fail to pass the pylorus in 24-48 hours
|
|
|
What are indications for surgical removal of a gastric FB?
|
>2cm wide
>5cm long sharp objects |
|
|
What are the common causes of pancreatitis in children?
|
-Trauma (handle bar injury)
-infection (mumps, influenza, EBV etc. salmonellosis, leptospirosis) -structural disease (choledochal cyst, duplication cyst, anomalous bile duct, duodenal stenosis) -systemic disease (cystic fibrosis, glycogen storage disease, familial hyperlipidemia, Kawasaki, HUS, HSP, Crohn's) -drugs or toxins (steroids, OCP, valproic acid, rifampin, thiazides) -idiopathic (mumps is the most common viral cause) |
|
|
What is a finding consistent with appendicitis on plain film?
|
An appendicolith
|
|
|
What is the obturator sign?
|
Pain elicited by having a patient internally rotate a flexed thigh against resistance
|
|
|
What are ultasonographic sings of appendicitis?
|
-enlarged non-compressible appendix that is painful during scanning
-presence of a fecalith |
|
|
What are the 2 most common considerations in the ddx of appendicitis?
|
IBD
mesenteric adenitis |
|
|
What is the cause of mesenteric adenines?
|
non-specific inflammation of mesenteric lymph nodes
|
|
|
What causes gallstones in children?
|
-hemolytic disease
-cystic fibrosis -TPN -sepsis -dehydration -ceftriaxone (sludging and biliary disease) |
|
|
What is hydrops of the gallbladder and what can cause it?
|
Fluid distension of the gallbladder from chronic cystic duct inflammation or obstruction
It can be caused by URTI, GI infection, Kawasaki, strep, mesenteric adenines, nephrotic syndrome and letospirosis |
|
|
What are 2 types of gallstones?
|
PIgment
Cholesteral |
|
|
What is a calculous cholecystitis?
|
Gallbladder inflammation in the absence of calculi
|
|
|
What is the gold standard for biliary tract imaging?
|
Cholescintigraphy (DISIDA scanning)
|
|
|
What is the most common cause of infectious diarrhea in children?
|
Rotavirus
|
|
|
What are common bacterial causes of infectious diarrhea?
|
Salmonella
Ecoli Campylobacter Shigella Yersinia Enterocolitica |
|
|
What are common protozoal causes of infectious diarrhea?
|
Entamoeba histolytica
|
|
|
What are enterotoxin-producing bacteria?
|
Salmonella
Shigella Vibrio Cholerae Ecoli C-difficile |
|
|
What is the definition of dysentry
|
Diarrhea associated with blood and mucus in the stool
|
|
|
When is rotateq given?
|
2,4 and 6 months
|
|
|
What other virus' cause GI symptoms?
|
Noravirus'
Hepatitis A virus |
|
|
What are animal reservoirs or Salmonella?
|
Poultry and reptiles
|
|
|
What are antibiotics used to treat salmonella?
|
Ampicillin
TMP-SMX |
|
|
What are antibiotics used to treat shigellosis?
|
Fluoroquinolones (adults)
Azithromycin (children) |
|
|
What are common causes of yersinia enterocolitica?
|
-undercooked pork
-unpasteurized milk |
|
|
What are common causes of vibrio cholera?
|
-undercooked shellfish
-raw vegetables |
|
|
What cases vibrio parahemolyticus?
|
Raw or undercooked seafood
|
|
|
What are 4 difference strains of Ecoli?
|
-Enteroinvasive (EIEC)
-Enterohemorrhagic (EHEC (Ecoli 0157:H7-> HUS) -Enterotoxigenic (ETEC) -Enteropathogenic |
|
|
Should antibiotics be used to treat Ecoli?
|
-Controversial
-It is possible that antibiotics increase the risk of developing HUS |
|
|
What are organisms should be considered in immunosuppressed patients with acute diarrheal illness?
|
-Normal causes of Acute diarrheal illness
-mycobacterium avium -cryptosporidium -CMV -adenovirus -c-diff -candida -pseudomonas |
|
|
How is ORS amount calculated?
|
-estimate losses as mild or moderate based on history, clinical signs and physical exam
-calculate 60cc/kg for mild and 80cc/kg for moderate give 25% of total ORS every hour for 4 hours, then RA the patient at 4hours -add emesis (volume for volume and stool volume 5cc/kg) |
|
|
What causes the majority of priapism in children?
|
SCD
Leukemia |
|
|
What are additional causes of priapism?
|
Spinal trauma
immunosuppressive disorders Anticoagulation Intracavernosal injection (papaverine, phentolamine and PGE1) |
|
|
What drugs may cause priapism?
|
phenothiazines
sedative hypnotics SSRI antihypertensives anticoagulants drugs of abuse |
|
|
What are types of priapism?
|
low flow (decreased venous outflow ->prolonged and painful)
High flow (penile arterial laceration - painless) |
|
|
What are cornerstones of management of priapism?
|
Hydration
Pain control Relief of urinary obstruction Ttx of underlying condition (Treatment should be initiated within 12 hours) |
|
|
What are treatment options for priapism?
|
Low flow
-Dorsal penile nerve block with 1% lidocaine -Sitz bath/hot compresses -Cavernosal aspiration -phenylephrine (intercavernous) (x-change transfusion is no longer recommended as it may be associated with ASPEN- association of scd priapism, x-change transfusion and neurologic events) High flow - arterial embolization Interventions should be initiated within 12 hours of symptom onset |
|
|
What is phimosis?
|
Constriction of the foreskin that prevents retraction of the prepuce over the glans
|
|
|
What are complications of phimosis?
|
-pain
-hematuria -urinary outlet obstruction |
|
|
When must the EP intervene in patients with phimosis?
|
-urinary outlet obstruction
-vascular compromise |
|
|
What is a paraphimosis?
|
-when the proximal foreskin cannot be returned to its anatomic location covering the glans resulting in distal venous congestion
|
|
|
What are causes of paraphimosis?
|
-infection
-masturbation -trauma -hair or clothing tourniquet -iatrogenic |
|
|
What is the management of paraphimosis?
|
-ice
-circumferential compression (over several minutes) -manual reduction (gentle steady pressure on the glans with both thumbs while the shaft is pulled straight) -puncture with a needle and squeezing to facilitate fluid drainage -dorsal band traction with Adson forceps -circumcision -dorsal slit procedure |
|
|
What is balanoposthitis? balanitis?
|
-Inflammation of the glans and foreskin
-Inflammation of the glans only |
|
|
What are causes of balanoposthitis?
|
-infection
-chemical irritation -trauma -fixed drug rash -contact dermatitis |
|
|
What is the management of balanoposthitis?
|
-hygiene
-sitz baths -antibiotics (anti-staph aureus and streppyogenes ie keflex 7d) -anti-inflammatory cream (0.5% hydrocortisone cream) |
|
|
What is the most common complication of circumcision and what is the treatment?
|
Hemorrhage
-direct pressure -silver nitrate -suture placement |
|
|
What is the treatment for zipper entrapment?
|
Cut the median zipper bar
|
|
|
What is epididymitis?
|
inflammation of the epididymis (located on the posterior aspect of the testicle)
|
|
|
What is the management of epididymitis?
|
-scrotal elevation
-ice -NSAIDs -narcotics |
|
|
What is the treatment of sexually acquired epididymitis?
|
>9yrs ->ceftriaxone 250mg IM and doxycycline 100mg Po BID
<9yrs -> erythromycin 50mg/kg PO QD x 7-14d |
|
|
What organisms cause chronic epididymitis?
|
Mycoplasma genitalium
ureaplasma urealyticum |
|
|
What is the testicular salvage rate with de-torsion @ 4 hours? @ 24hours?
|
-96%
-10% |
|
|
What are clinical features of testicular torsion?
|
-Acute scrotal apin
-Swelling -An elevated testicle -absent cremasteric reflex |
|
|
What is the study of choice to assess for testicular torsion?
|
-color flow doppler
|
|
|
How is manual de-torsion performed?
|
Rotating the testicle in open book fashion from medial to lateral
|
|
|
What sign is pathognomic of appendix testis torsion?
|
-"the blue dot sign" a small area of bluish hue <3mm across the upper lateral portion of the hemiscrotum
|
|
|
What is a varicocele?
|
A collection of venous varicocities of the spermatic veins in the scrotum caused by incomplete drainage of the pampiniform plexus
|
|
|
What are causes of a right-sided varivocele? left-sided varicocele?
|
-Right - IVC thrombosis or compression
-Left - Left renal vein obstruction |
|
|
What is a hydrocele?
|
A collection of fluid that accumulates in the tunica vaginalis. They may be communicating or non-communicating with the peritoneum
|
|
|
What is the management of hydrocele?
|
Hydroceles may be present at birth but they often resolve spontaneously by 18 months
<1year duration - if no pain (asymptomatic) d/c home with urology follow up ->1 year duration or >18 months - US to r/o reactive hydrocele caused by a testicular tumour or inflammation |
|
|
What is an indirect hernia?
|
Lack of processes vaginalis obliteration with abdominal contents invagination through the sac
|
|
|
What are reduction techniques for inguinal hernia
|
-Slow gentle pressure application
-pull hernia to straighten out entrapped contents allowing it to slip back into the abdomen |
|
|
What population of children are most at risk of UTI?
|
-Girls<2yrs
-male6-12 months -uncircumcised bosy -fever>48-72h |
|
|
What bacterial pathogens casue UTI in children
|
E-coli
enterobacter proteus morganella serratia salmonella |
|
|
What is the cause of UTI in neonates?
|
bacteremia
|
|
|
What is the cause of UTI in older children
|
infection in the lower tract tracking upwards
|
|
|
How can you tell that a urine sample is contaminated?
|
>10wbc/HPF and epithelial cells
|
|
|
Is a urinalysis sufficient to r/o UTI in a child <2years of age?
|
NO
|
|
|
What are the definitions of UTI on culture?
|
-suprapubic catheter >10^2 CFU/cc, one pathogen
-urethral cathetter >10^4 CFU/cc, one pathogen -midstream urine >10^5 CFU/cc, one pathogen |
|
|
What is the differential diagnosis of dysuria in children?
|
irritants
retained FB balanitis (males) accidental injury sexual or physical abuse UTI vaginitis pinworms |
|
|
What is the management of an infant <2mo with a UTI?
|
Admit to hospital
IV abs - ampi/genta |
|
|
What is the mgmt of a child 2mo-2yr with a UTI?
|
-If well, can consider outpatient management
-10-14d antimicrobial therapy (b/c disease of the upper tract) Additional outpatient follow-up including appropriate imaging studies is recommended to determine the presence of renal scarring, posterior urethral valves or vesicoureteral reflux |
|
|
What are options for oral therapy in the ttx of paediatric UTI?
|
-amoxicillin
-augmentin -TMP-SMX -Cephalexin -Cefixime |
|
|
What is the definition of microscopic hematuria?
|
>5 rbcs/HPF
|
|
|
What are causes of red urine other than blood?
|
Phenothiazines
Ibufprofen beets blueberries urate crystals (neonates) serratia marcescens |
|
|
What are aetiologies of hematuria in children?
|
Extrarenal (trauma, meatal stenosis, menstruation, rectal bleeding)
Intrarenal (pyelo, stones, PSGN, interstitial nephritis, Polycystic kidney disease, ATN, basement membrane disease, RV and RA thrombosis) Systemic (HSP, SLE, HUS, SCD, endocarditis, bleeding disorder, meds, munchausen) |
|
|
What findings on urine microscopy suggest glomerular disease?
|
Casts or proteinuria
|
|
|
In a patient with edema and proteinuria, what tests should be ordered?
|
-electrolytes
-total protein -albumin |
|
|
What are the types of renal stones?
|
-calcium containing (most common)
-struvite -uric acid -cysteine |
|
|
Why are NSAIDS effective in renal colic?
|
It is an analgesic directly related to the inhibition of PG mediated contraction of the ureter
|
|
|
What is the imaging modality of choice for renal masses in children?
|
US,b/c a significant # of masses are cysts.
|
|
|
Why should urine catecholamines be ordered in patients with new renal masses?
|
Urine catecholamines are increased in 95% of children with neuroblastoma
|
|
|
Is trace proteinuria (1-2+) concerning in a child?
|
no, it can be seen in up to 85% of children
|
|
|
What are the causes of proteinuria?
|
Glomerular (nephrotic syndrome, glomerulonephritis, post transplantation rejection)
Tubular (heavy metal poisoning, UTI, diabetes) |
|
|
What causes false + urine dipsticks for protein?
|
alkaline urine
mucus blood vaginal secretions semen significant #s of inflammatory cells |
|
|
Does antibiotic treatment of strep pharyngitis decrease the risk of PSGN
|
No
|
|
|
What are lab findings in PSGN?
|
-increased ASO
-increased immunoglobulin G -decreased complement, especially C3 |
|
|
What are the characteristics of nephrotic syndrome?
|
-hypoproteinemia
-proteinuria -edema -hyperlipidemia -prothrombotic |
|
|
What types of nephrotic syndrome exist?
|
primary nephrotic syndrome (diseases limited to the kidney)
secondary nephrotic syndrome (from systemic disease) |
|
|
What is the definition of nephrotic syndrome?
|
>3.5g protein in 24 hours
|
|
|
What is the treatment of hyperkalemia with ECG changes?
|
calcium chloride 20-30mg/kg/dose IV
bicarbonate 1-2mEq/kg/dose glucose 0.5-1.0g/kg insulin 1U/4g glucose |
|
|
What is the treatment for hyponatremic seizure?
|
3-5cc/kg 3% NaCl
|
|
|
How do you determine correct BP cuff size?
|
-the air bladder should cover 80-100% of the circumferences of the arm and 2/3 of the length of the upper arm
|
|
|
What are the definitions of urgent HTN in children?
|
<10yrs SBP >160 DBP >105
>10yrs SBP >170 DBP >110 no signs of end organ damage |
|
|
What is the definition of hypertensive emergency
|
severe increase in BP associated with acute neurologic changes or encephalopathy, pulmonary edema, myocardial ischemia or proteinemia
|
|
|
What is the goal in managing a hypertensive emergency ?
|
decrease MAP by 10-20% over minutes to hours
|
|
|
What is HSP?
|
It is an immunoglobulin A mediated systemic vasculitis involving small BV of the GI tract, skin and joints
|
|
|
What are predisposing factors to HSP
|
URTI
Group A Strep culture + |
|
|
What are the hallmarks of HSP?
|
-Palpable purpuric/petechial rash on LE
-arthralgia -GI symptoms -glomerulonephritis with hematuria |
|
|
What is the most common offending agent in HUS?
|
E coli 0157:H7
|
|
|
What is the pathophysiology of HUS?
|
-injury to renal vascular endothelium
-microcytic angiopathic hemolytic anemia (damage to rbc, platelets, increased fibrin) |
|
|
What are the signs of HUS?
|
Bloody diarrhea with abdo pain followed by acute onset thrombocytopenia, hemolytic anemia and acute renal insufficiency
|
|
|
What are findings of microagiopathic changes on a peripheral blood smear?
|
-tear drop cells
-helmet cells -microspherocytes -burr cells |
|
|
What are the most common causes of bacterial meningitis in neonates?
|
GBS
Ecoli (Listeria is rare but is impt to think about because of its resistance to cephalosporins) |
|
|
What are the most common pathogens for bacterial meningitis in infants and children?
|
S pneumoniae
N meningitidis |
|
|
How does bacterial meningitis develop?
|
-infection of the respiratory tract
which causes bacteria which invades the meninges and causes inflammation. (Rarely meningitis is the result of direct extension from a contiguous focus) |
|
|
What is the rate of serious bacterial illness and acute bacterial meningitis with fever in the 1st 3 months of life?
|
SBI - 4-15%
ABM 1-2% |
|
|
How can seizures manifest in neonatal acute bacterial meningitis
|
Hypertonicity
A vacant stare Trembling of the chin Bicycling movements of the extremities |
|
|
What is Kernig's sign?
|
Flexion of the hip 90 degrees with subsequent pain on extension of the leg
|
|
|
What is Brudzinski's sign?
|
Involuntary flexion of the hips and knees following passive flexion of the neck performed when patient is supine
|
|
|
What are clinical signs associated with and increased risk of intracranial infection?
|
-lethargy
-decreased motor tone -doll's eye sign -inability to fix and follow -decreased response to pain stimuli -nuchal rigidity -full fontanelle -petechiae -poor skin perfusion |
|
|
Are petechiae above the nipple line concerning for meningitis?
|
Not if the child is well
|
|
|
When are CNS infections typically seen post dural tears?
|
Generally within 2 weeks of the initial injury
|
|
|
when is an LP contraindicated in suspected meningitis?
|
-rapid progression to deep coma
-focal neurologic signs suggestive of an abscess |
|
|
What are ways to decrease post lumbar puncture cephalgia?
|
-smaller gauge needle
-restricting the sample fluid to 3mL -re-inserting the stylet before removing the needle |
|
|
What is the standard CSF examination for ABM?
|
-Tube 1 bacterial culture and gram stain
-Tube 2 protein and glucose -Tube 3 Blood cell count |
|
|
How long after antibiotic administration can the csf profile be unaffected?
|
12-24 hours
|
|
|
What is the normal csf:serum glucose ratio in children?
|
0.6
|
|
|
What is the csf:glucose ratio in ABM?
|
0.4 (therefore csf glucose is decreased in ABM)
|
|
|
What is the significance of protein in the csf?
|
-increased protein is seen in both viral and bacterial meningitis (the presence of rbcs in the csf will elevate the protein content 1mg/dL for every 300-1000 rbcs)
|
|
|
Is it normal to have polymorphonuclear leukocytes in csf?
|
In the 1st month of life up to 60% of the cells may be PMNs but beyond 1 month not more than 3PMN/mm^3 should be seen
|
|
|
What is the most effective diagnostic test in partially treated meningitis?
|
Antigen testing. Antigens remain measurable after antibiotic treatment
|
|
|
What are the csf findings in viral meningitis?
|
Modest increase in PMNs
Normal glucose Normal to slightly increased protein negative Gram stain |
|
|
What is reasonable empiric therapy for meningitis?
|
0-4wks - cefotaxime 50mg/kg (or ampi/genta)
4wks-2mo - ceftriaxone 100mg/kg + ampicillin >2mo Ceftriaxone and vancomycin (especially if gram + cocci on gram stain) |
|
|
What is the main proven usefulness of dexamethasone in children with ABM?
|
>8wks of age with Hflu ABM
It can mitigate some of the neuro sequelae especially the hearing loss. However physicians should wait for the gram stain and if it fits Hflu (gram negative ) then dexamethasone 0.15mg/kg should be administered |
|
|
When should acyclovir be added to the treatment for acute bacterial meningitis in children?
|
Infants <3mo who are ill or febrile and
-history of maternal HSV infection -presence of vesicles -seizure -focal neuro signs -atypical presentations of sepsis or meningitis |
|
|
What is the definition of epilepsy?
|
The occurrence of 2 or more unprovoked seizures
|
|
|
Do seizures cause brain damage in children?
|
Children with epilepsy are at significant risk for cognitive impairment but this may be multifactorial
|
|
|
What are the two main types of seizures?
|
Generalized (with loss of consciousness)
Partial (consciousness maintained) |
|
|
What is the difference between simple and complex partial seizures?
|
In complex partial seizures the patient experiences some change in their level of awareness
|
|
|
What are infantile spasms and what is their significance?
|
-Jackknife flexor or extensor spasms appearing in clusters
-2/3 of children with infantile spasms have an underlying CNS disorder |
|
|
What are the criteria for a simple febrile seizure?
|
-<15min
-6mo-5yrs - neurologically and developmentally normal -generalized -fever -<1/24 hour period |
|
|
What is the chance that a child with a febrile seizure will develop epilepsy?
|
2% compared to the baseline risk of 1%
|
|
|
What are metabolic disturbances that may cause neonatal seizures?
|
Hypoglycemia
Hypocalcemia Hypomagnesemia Pyridoxine dependency Inborn errors of metabolism Drug withdrawal or intoxication |
|
|
What is the definition of status epileptics?
|
Continuous seizure activity >30min or sequential seizures over the same period without full return of consciousness between
|
|
|
What is the differential diagnosis of patients presenting with seizure?
|
Syncope
migraine Breath holding narcolepsy Other disorders of sleep tics Shudder attacks Paroxysmal choreoathetosis panic attacks psychogenic seizures Sandifer's syndrome |
|
|
What are the 3 main etiologic categories of seizures
|
Acute symptomatic (provoked by an acute event)
Remote symptomatic (due to an earlier remote CNS lesion) idiopathic seizures (no definable cause) |
|
|
What is the definition of hypoglycaemia?
|
<60mg/dL (3.3mmol/L) in adults, and <40mg/dL (2.2mmol/L) in children
|
|
|
What are the types of post traumatic seizures?
|
impact seizures (within 1 hour of head trauma) - these are not associated with severe injury or later development of epilepsy
early post traumatic seizure (occur within the 1st week of injury) - these may result from cerebral edema, hemorrhage, laceration or contusion |
|
|
Do tumours often cause seizures in children?
|
No tumours are often infratentorial and as such do not cause seizures
|
|
|
What are RF for ischemic stroke in children?
|
Homocystinuria
Congenital Heart disease Sickle cell anemia |
|
|
What causes hemorrhagic stroke in children?
|
Vascular malformations
|
|
|
What are causes of remote symptomatic seizures?
|
Congenital brain malformations
Neurocutaneous disorders Cerebral palsy |
|
|
What are the AAP recommendations for lumbar puncture in febrile seizures?
|
Unnecessary in >18months of age without clinical findings suggestive of meningitis
-should be considered in 12-18monts -should be strongly considered in <12months (signs of meningitis can be subtle) |
|
|
What is the treatment for hypoglycaemia in children?
|
2-4cc/kg D25
|
|
|
What is the treatment for hyponatremic seizures?
|
4cc/kg of 3% NaCl
|
|
|
What is the treatment of hypomagnesemia?
|
0.25cc/kg 50% magenesium sulfate solution
|
|
|
What is the treatment of hypocalcemia?
|
100mg/kg of calcium gluconate IV or 20mg/kg 10% calcium chloride
|
|
|
What is the treatment for seizures resulting from isoniazid ingestion?
|
-1mg pyridoxine for each 1 mg of isoniazid. 5mg is given if unknown dose of isoniazid
|
|
|
Which patients with seizures should be empirically treated for herpes encephalitis?
|
Those with altered mental status and focal seizures if rbcs are present in the csf
|
|
|
What is different about neonatal seizures?
|
-common underlying causes differ from older children or adults
-bloods should be done (incl calcium, magnesium, phosphate and ammonia) -LP should be done -empirical antibiotic therapy and acyclovir should be initiated -treatment for hypoglycaemia, hypocalcemia and hypomagnesemia -phenobarb load 20mg/kg |
|
|
What are steps in the management of status epileptics?
|
-position patient to maximize ventilation
-administer oxygen, consider nasal trumpe -manage the airway if necessary -insert IV and send bloods administer medications (BXD, phenytoin, phenobarb) |
|
|
What are the doses of lorazepam and diazepam in paediatrics?
|
lorazepam 0.1mg/kg (max 8mg)
diazepam 0.2-0,5mg/kg (max 10mg) |
|
|
What is the dose of rectal diazepam?
|
0.5mg/kg (max 20mg) (lubricated feeding tube 4-6cm into rectum if the rectal formulation is not available)
|
|
|
What is the loading dose and rate for phenytoin, fosphenytoin and phenobarb?
|
phenytoin 18-20 mg/kg @ 1mg/kg/min max 50mg/min
fosphenytoin 18-20PE/kg @ 150mg/min Phenobarbitol 20mg/kg @ 1 mg/kg/min (max 50mg/min) |
|
|
What is the dose of midazolam in children?
|
0.2mg/kg bolus
Drip 0.1mg/kg/hr |
|
|
Why is phenytoin a poor long term anticonvulsant
|
Hirsutism
gum hyperplasia facial coarsening |
|
|
What are the 5 temporal patterns of HA?
|
Acute
Acute recurrent Chronic Progressive Chronic nonprogressive Mixed |
|
|
What are warning signs for a symptomatic HA (as opposed to primary headaches such as migraine or tension)?
|
-recent onset
-occurrence with straining or athletics -associated with neurologic symptoms -change in HA pattern -nocturnal awakening -bilateral occipital |
|
|
What are causes of increased ICP?
|
-brain tumours
-pseudotumor cerebri -hydrocephalus -brain abscess -intracranial bleeding |
|
|
What are classic symptoms of increased ICP?
|
HA that awakens a child or nocturnal/morning emesis
|
|
|
What are clinical findings of pseudotumor cerebri?
|
Papilledema
6th CN Visual field obstruction |
|
|
What is associated with pseudotumor cerebri?
|
-obesity
-use of outdated tetracyclines -OM -head trauma -vitamin A -steroids -birth control pills -tetracyclines |
|
|
What is the definition of a migraine without aura?
|
Headache lasting 1-48 hours.
2 of the following: -either bilateral or unilateral -pulsating quality -moderate to severe intensity -aggravated by routine physical activity 1 of the following: -nausea and/or vomiting -photophobia and/or phonophobia |
|
|
What are the main features that differentiate the paediatric from the adult migraine?
|
Shorter duration (1-48hours) vs 1-72hour in adults
Unilateral or bilateral phono or photophobia as opposed to phono and photophobia |
|
|
What is an abdominal migraine?
|
Recurrent abdominal pain, nausea, vomiting and recurrent headaches
|
|
|
What is the definition of migraine with aura (classic migraine)?
|
At least 2 episodes with the following criteria:
1)reversible symptoms arising from focal cerebral or brainstem dysfunction 2) gradual development over >4mins or several symptoms that occur in succession 3)aura with a duration of <60min 4) the appearance of headache either before, simultaneously with or within 60 min of aura (auras are most commonly visual) |
|
|
WHat is a hemiplegic migraine?
|
sudden onset of hemiparesis or hemisensory loss along with headache in the contralateral hemisphere
|
|
|
What is an ophthalmoplegic migraine?
|
HA with severe unilateral pain followed by ipsilateral 3rd nerve palsy
|
|
|
What is a basilar migraine?
|
Common in children
visual symptoms (bilateral blindness/blurred vision) and visual hallucinations, vertigo, ataxia, LOC, drop attacks |
|
|
What is the Alice in Wonderland syndrome?
|
perceptions of distortion in body images and shapes
|
|
|
What should you evaluate a child for if they have head tilt, vomiting and a HA?
|
A posterior fossa lesion
|
|
|
What is an ocular migraine?
|
Transient monocular visual blurring to blindness with bright flashes of light
|
|
|
What is a tension HA?
|
Nonthrobbing, pressing or band-like tightness of mild to moderate intensity in the absence of nausea, vomiting and aura
|
|
|
What is a cluster HA?
|
One to several attacks recurring each 24 hours over several weeks to months
Throbbing severe, unilateral pain in the orbitotemporal region associated with ipsilateral scleral injection, lacrimation, nasal stuffiness and partial Horner's syndrome |
|
|
What lesions is MRI particularly good at evaluating in the brain?
|
sella turcica
temporal lobes posterior fossa cervicomedullary junction AVM low-grade tumours |
|
|
What causes chronic progressive HA?
|
Disorders that cause progressive severe HA in children usually from increased ICP
|
|
|
When should a CT head be done in children with HA?
|
abnormal neurologic findings
signs and symptoms of elevated ICP meningeal signs and focal neuro deficits or AMS progressive or new neuro signs significant head trauma severe nocturnal HA that awakens the patient "worst headache of my life" VP shunt chronic progressive HA |
|
|
When should CT be considered in a child with a HA?
|
HA or vomiting on awakening
unvarying location persistent HA with no family history of migraine age <3years |
|
|
When is LP necessary in HA?
|
When there is concern about an
infectious etiology hemorrhage pseudotumor cerebri |
|
|
What are options for the treatment of migraine in children?
|
acetaminophen 10-15mg/kg
ibuprofen 5-10mg/kg ketorolac 0.5mg/kg codeine 0.5-1.0mg/kg/dose oxycodone 0.05-0.15mg/kg promethazine 0.25-0.5mg/kg (12.5-25 mg in adults) metoclopramide 0.5-2mg/kg |
|
|
In what patients should sumatriptan be avoided?
|
cardiac patients
Hypertensive patients those who received an ergot alkaloid in the preceding 24 hours |
|
|
Lesions in what areas may cause ataxia?
|
Cerebellum
Corticospinal tract Dorsal Columns (Also inherited metabolic or genetic disorders) |
|
|
What is the most common cause of acute cerebellar ataxia?
|
Varicella
|
|
|
What are aetiologies of childhood ataxia?
|
Acute cerebellar ataxia
Acute post infectious demyelinating encephalitis brainstem encephalitis drug ingestion GBS metabolic disorders migraine MS neoplasm opsoclonus-myoclonus syndrome recurrent genetic ataxia siezure stroke vertebral artery dissection |
|
|
How can you distinguish acute cerebellar ataxia from post infectious demyelinating encephalomyelitis?
|
PIDEM has alteration of consciousness and multifocal neuro deficits as well as fever and the frequent occurrence of seizures
|
|
|
What agents cause brainstem encephalitis?
|
EBV
L monocytogenes enterovirus |
|
|
What percent of childhood ataxia is due to drug toxicity? What agents are most commonly involved?
|
32%
Anticonvulsants BZD alcohol antihistamines |
|
|
What % of childhood brain tumours arise in the brainstem or cerebellum?
|
45-60%
|
|
|
What is the opsoclonus-myoclonus syndrome?
|
ataxia
rapid chaotic multidirectional eye movements myoclonic jerks |
|
|
What is opsoclonus-myoclonus syndrome commonly a presenting manifestation of ?
|
neuroblastoma
ganglioneuroblastoma |
|
|
What is Miller Fisher variant of GBS?
|
ataxia
areflexia ophthalmoplegia of vertical gaze |
|
|
What metabolic problems may case ataxia?
|
urea cycle defects
defects in pyruvate and lactate metabolism Niemann-Pick Tay-sachs Wilson's |
|
|
What are 2 genetic disorders that cause ataxia?
|
Friedrich's ataxia
Ataxia telangiectasia |
|
|
What is Menieres disease?
|
vertigo
fluctuating hearing loss tinnitus |
|
|
What is the history of vestibular neuritis/
|
vertigo without hearing loss (preceded by a viral infection)
|
|
|
What is the history of labyrinthitis?
|
vertigo, hearing loss and tinnitus
|
|
|
What are clinical signs of a peripymphatic fistula?
|
Valsalva that precipitates vertigo
Hennebert's sign: nystagmus after negative pressure is exerted in the ear |
|
|
What is the treatment for a perilymphatic fistula?
|
Surgical repair
|
|
|
Define syncope?
|
A sudden, reversible, typically brief LOC (20-60s) and loss of muscle tone that resolves without intervention
|
|
|
What is the division of causes of syncope?
|
Autonomic
Cardiac noncardiac |
|
|
Which causes of cardiac syncope in children may be life-threatening?
|
cardiomyopathy (restrictive, hypertrophic, dilated)
post-op congenital heart changes (Fontan, mustard) Congenital coronary artery abnormalities Myocarditis aortic stenosis pulmonary hypertension |
|
|
What cardiac electrical disorders may cause syncope?
|
Long QT
WPW AV block idiopathic v fib Brugada |
|
|
Which groups are at increased risk for cardiac syncope?
|
-athletes
-patients with eating disorders or chronic fatigue -patients who use illicit substances -survivors of congenital heart disease |
|
|
What factors distinguish the paediatric MSK system from that of the adult?
|
-presence of a physis
-thick physiologically active periosteum -growing bone is more porous/pliable and less dense -greater remodelling potential with metaphyseal #s |
|
|
What are the 4 types of paediatric fractures?
|
-plastic deformation
-torus # -greenstick # -complete |
|
|
What X-ray view should be requested with high suspicion for clavicle # but negative AP?
|
-30degree cephalic view
|
|
|
When should ortho consults be obtained for clavicle fractures?
|
-open
-neurovascular compromise -rib cage # -100% displacement of fracture fragments with skin tenting |
|
|
What is the most common elbow # in paediatrics?
|
supracondylar fracture
|
|
|
What is the most common supracondylar elbow #?
|
extension type (95%) (posterior displacement of the distal fragment
|
|
|
What is the Gartland classification of extension-type supracondylar fractures?
|
Type I - non-displaced
Type II - displaced # with intact posterior cortex Type III displaced fracture with no cortical contact A - posterior medial rotation of the distal fragment B - posterior lateral rotation of the the distal fragment |
|
|
How is distal sensory status in the hand assessed?
|
2-poit discrimination (>6mm is abnormal)
|
|
|
What are indications for assessment of compartment pressures in supracondylar elbow fractures?
|
-pain on flexion/extension of the fingers
-forearm tenderness -pain that is disproportionate to the injury |
|
|
What are the characteristics of Volkman's ischemic contracture?
|
-elbow flexion
-pronation -wrist flexion -MCP extension -interphalageal flexion |
|
|
What are the ossification centres of the elbow?
|
Capitellum
Radius Internal (medial) Trochlea Olecranon External (lateral |
|
|
What are the approximate ages of ossification?
|
1,3,5,7,9,11
|
|
|
How can you be certain that your lateral elbow view is a true lateral?
|
-figure of eight appearance to distal humerus
-bisection of the capitellum by the anterior humeral line |
|
|
What is a normal value for Baumanns angle
|
75 degrees
|
|
|
When should an EP attempt reduction of a supracondylar fracture?
|
pulseless, pale, cold, hand and no ortho immediately available
|
|
|
What are the primary complications of supracondylar injuries?
|
-median nerve injury
-radial nerve injury -bracheal artery injury |
|
|
What is a monteggia fracture-dislocation?
|
-fracture of the proximal 1/3 of the ulna with dislocation of the radial head
|
|
|
When should a monteggia fracture-dislocation be suspected?
|
in any isolated ulnar #
|
|
|
What is the pathoanatomic reason for radial head subluxation?
|
The annular ligament slips into the radiocapitellar joint
|
|
|
What are the methods to reduce radial head subluxation
|
hyperpronation
flexion-supination |
|
|
What is a toddler's fracture?
|
oblique nondisplaced fractures (previously only in the tibia but now the term is used more loosely)
|
|
|
What should prompt evaluation for trauma X
|
spinal # without adequate history
midshaft # tibial fracture in nonambulatory children |
|
|
What are the consequences of missing child abuse?
|
35% chance of repeated abuse
10% chance of death |
|
|
What fracture patterns are worrisome for abuse?
|
# in a child <1year
fractures at different stages of healing bilateral or multiple fractures |
|
|
What injuries are particularly concerning for non-accidental injury?
|
-complex skull #
-rib #s -metaphyseal #s -vertebral #s or subluxations -midshaft humeral # -scapular # -femoral #s |
|
|
What is the most common manifestation of child abuse?
|
diaphyseal # (humerus/femur/tibia are most frequent)
|
|
|
What #s are most specific for child abuse
|
metaphyseal fractures
|
|
|
Where are post-resuscitation rib#s found
|
anteriorly
|
|
|
Where are non accidental rib #s found?
|
posteriorly
|
|
|
What conditions can mimic non-accidental injury?
|
-normal variant metaphyseal findings
-osteogenesis imperfecta -rickets -mekes' kinky hair syndrome -hypervitaminosis A -congenital syphillis |
|
|
What is developmental dysplasia of the hip (DDH)
|
The spectrum of disease from subluxable hips to frank dislocation
|
|
|
What are physical exam findings in DDH?
|
leg length, skin fold and ROM asymmetry
abnormal Barlow and Ortolani |
|
|
What is the most common cause of hip pain in childhood?
|
Transient synovitis
|
|
|
What are 4 independent multivariate predictors of septic arthritis?
|
-ESR 40mm/hr or higher
-serum white cell count >12,000cells /ul -inability to WB -fever |
|
|
What is the chance that a patient has septic arthritis with 3/4 of the independent multivariate predictors of septic arthritis? 4/4?
|
-93%
-99% (initially) in the validation phase of these criteria it was 93%, when repeated at another institution it was 59% |
|
|
What are radiographic findings consistent with septic arthritis
|
The presence of a large joint effusion.
-periarticular soft tissue swelling -widening of the joint space -obliteration or displacement of the gluteal lines -asymmetrical fullness of the iliopsoas and obturator soft tissue planes |
|
|
What is empiric therapy for septic arthritis in children?
|
birth->2mo nafcillin and cefotaxime
2mo and older -> nafcillin and ceftriaxone (consider vancomycin) |
|
|
What are the most common pathogens for septic arthritis in children?
|
birth->2mo GBS, staph aureus, gram -ve rods, n gonorrhea
2mo->5years staph aureus, step pneumo, strep pyogenes, kingella kingae, Hflu 5yrs -12 years staph aureus, strep progenies >12years staph aureus and n gonorhea |
|
|
What factors are associated with Legg-Calve-Perthes disease?
|
-breech presentation
-later birth order -lower socioeconomic status -higher parental age -lower birth weight -ADHD -delayed bone age -short stature -passive smoke inhalation -HIV -chronic renal disease |
|
|
What hip motions are limited in Legg-Calve-Perthes?
|
abduction and internal rotation
|
|
|
What is SCFE?
|
The posterior and inferior slippage of the proximal femoral epiphysis on the metaphysis
|
|
|
What % of patients have bilateral SCFE?
|
80%
|
|
|
What factors are associated with SCFE?
|
endocrine disorders (hypothyroid, panhypopituitarism, hypogonadism, GH replacement), renal osteodystrophy, radiation therapy
|
|
|
What is the new classification system for SCFE?
|
stable (ambulation possible)
unstable (ambulation not possible) |
|
|
What views are used to make the diagnosis of SCFE?
|
AP and lateral radiographs of both hips
|
|
|
What are findings consistent with SCFE on AP radiograph?
|
Klein's line - a line from the superior neck of the femur that normally intersects or falls within the epiphysis
blanch sign of steele - a crescent shaped area of increased density in the proximal femoral neck created by superimposition of the posteriorly displaced epiphysis on the femoral neck |
|
|
What are short-term complications of SCFE?
|
avascular necrosis
chondrolysis |
|
|
What is an apophysis?
|
a cartilagenous structure that serves as a site for insertion of tendons on growing bone
|
|
|
What is apophysitis?
|
inflammation of an actively growing bony prominence that is under great tensile strength
|
|
|
What are common apophyseal injuries?
|
Osgood- schlatter
sever's disease medial epicondylitis |
|
|
What is the presentation of Osgood-Schlatter's disease
|
Tenderness, pain, and swelling at the insertion site of the patellar tendon on the tibial tubercle
It is worsened by running or jumping |
|
|
What is Sever's disease? How does it manifest?
|
Apophysitis of the calcaneus due to traction by the gastrocnemius-soleus complex
manifests as posterior heel pain in 8-13 year old athletes |
|
|
What are exam findings in medial epicondylitis?
|
localized tenderness and swelling over the medial epicondyle and pain with resisted flexion of the wrist
|
|
|
What is the management
of avulsion fractures? |
<2cm in the hip or <5cm at the medial epicondyle - immobilization
If wider separation, may benefit from open reduction |
|
|
What are approximate weights of newborns, 6mo, 1 year, 3 year, 5 year, 7 year, 9 year, 11 year, 13 year, 15 year, 17 year
|
Newborn = 3kg
6 mo = 6 kg (2 x BW) 1 year = 10kg (3 x BW) 3 year = 15 kg (then add 5 kg for every odd year until 11 and then add 10kg/ odd year) 5 year = 20kg 7yr = 25kg 9 yr = 30kg 11 year = 35 kg 13 year = 45 kg 15 year = 55kg 17 year = 65kg (beyond 1 year of life (agex2) + 10 |
|
|
What is the pediatric assessment triangle?
|
Appearance
Work of Breathing Circulation |
|
|
What falls under appearance in the pediatric assessment triangle?
|
tone
irritable interactive consolable look/gaze speech |
|
|
What falls under work of breathing in the pediatric assessment triangle?
|
Abnormal sounds (stridor, grunting, snoring, wheezing)
abdnormal positioning (sniffing, tripoding) refusal to lie down head bobbing nasal flaring retractions |
|
|
What falls under circulation in the pediatric assessment triangle?
|
Pallor
Mottling Cyanosis Petechiae |
|
|
Differentiate cutis marmorata and mottling of the skin?
|
Cutis marmorata: normal finding commonly seen in infants in a cool ambient environment
Mottling: reflects decreased perfusion to the skin due to shock |
|
|
What is normal feeding for an infant?
|
Normal intake per feed in ounces (up to 6 months) is age in months + 3
Normal frequency q2h for 0-3 months q3-4 hours at 3 months Poor feeding is <50% of normal intake 1 ounce = 30mL |
|
|
What is the normal frequency of urination for infants?
|
Minimum 4x/day
|
|
|
How does fever affect heart rate?
|
Increase in Temp by 1 degree -> increase in HR by 10bpm
Max HR attributable to fever is 160bpm If HR >200bpm likely SVT |
|
|
What is the differential for an infant that is crying continuously and inconsolable?
|
Infection
Meningitis Sepsis OM UTI Metabolic abnormalities Hypoglycemia Hyper/hyponatremia ENT/Optho Corneal abrasion or FB FB in the ear or nose Trauma Hair tourniquet (figer, toes, pénis) Open diaper pin Fall Child abuse BU Phimosis/paraphimosis GI Incarcerated hernia Intestinal colic Anal fissure Breastfeeding Mom is breastfeeding and taking drugs (ex cocaine) Improper feeding practices |
|
|
At what age do the fontanelles close?
|
Anterior 24 months
Posterior 2 months |
|
|
At what age does the child roll from front to back? back to front?
|
4 months
5 months |
|
|
At what age does the child sit unsupported?
|
6 months
|
|
|
At what age does a child walk alone?
|
12 months
|
|
|
At what age does a child go up and down steps without help?
|
24 months
|
|
|
At what age does a child support themselves on their forearms?
|
3 months
|
|
|
At what age the an infant follow objects to the midline? past the midline?
|
1 month
2 months |
|
|
At what age does an infant respond to visual threats?
|
3 months
|
|
|
At what age does an infant use the pincer grastp
|
9 mo
|
|
|
How many blocks can be stacked at 15, 18, 21 months?
|
2
3 5 |
|
|
When does a child smile socially?
|
2 months
|
|
|
At what age does a child enjoy looking around?
|
4 months
|
|
|
What are historical indicators of child abuse (5)?
|
unexplained delay in seeking medical care
History does not explain the injury History changes with time Child has 'magical injuries' History is not consistent with child's developmental abilities |
|
|
What are bruises suggestive of child abuse (5)?
|
Any unexplained bruising under 9 months
Multiple bruises of different ages Pattern injuries (handprint, belt mark, cord loop, linear marks, bite marks) Unusual distribution of bruises (neck groin, inner thigh) Restraint marks on wrists or ankles |
|
|
What is the clinical croup score?
|
'CARLS'
Cyanosis (5) (with aggitation 4, at rest 5) Air entry (0-2) Retractions (0-3) LOC (5) Stridor (0-2) |
|
|
What is the PRAM score
|
Oxygen saturation (0-2)
Suprasternal retractions (0-2) Scalene contraction (0-2) Air entry (0-3) Wheezing (0-3) Mild 1-4 Moderate 5-8 Severe 9-12 Validated in 2-18years |
|
|
Where does the umbilical vein lead?
|
To the ductus venosus, through the liver into the inferior vena cava
|
|
|
Where do the umbilical arteries go?
|
The originate from the abdominal aorta and lead to the placenta
|
|
|
What are the most common reasons for pediatric visits to the ED?
|
trauma
respiratory emergencies |
|
|
What are the most common diagnosis is pediatric ED patients?
|
Acute respiratory infections
fever OM and other head and neck infections enteritis minor cuts and contusions |
|
|
What is the weakest part of growing bone?
|
Physeal plate
|
|
|
What % of peds fractures are physeal?
|
20%
|
|
|
What is useful in measuring HR?
|
Quality and a comparison of central and peripheral pulses
|
|
|
What is the proper BP cuff size?
|
Bladder covers 2/3 circumference of the arm and at least 50% of the upper arm
|
|
|
What criteria define abnormal periodic breathing?
|
If it is associated with decreased HR or decreased oxygen saturation
|
|
|
What is normal behaviour for a 6 month old?
|
curiosity
anxiety it is worrisome if the child does not acknowledge your presence |
|
|
How is fever defined?
|
Any elevation in body temperature >/= 38
|
|
|
What is the most reliable way to measure body temperature?
|
Rectal
|
|
|
Differentiate fever and hyperthermia?
|
Hyperthermia is an elevation in the body's set point
|
|
|
What is the definition of serious bacterial illness?
|
The presence of pathological bacteria in a previously sterile site (UTI, bacteria, meningitis, osteomyelitis, bacterial gastroenteritis, bacterial pneumonia, cellulitis, septic arthritis)
|
|
|
What is the most common site of infection in children <3 months?
|
UTI
|
|
|
What are the most common bacterial causes of fever in 0-28d?
|
Group B Strep
Listeria E coli C trachomatis N gonorrhea |
|
|
What are the most common bacterial causes of fever in 1-3 month olds?
|
S pneumoniae
H influenza N meningitidis E coli |
|
|
What are the most common bacterial causes of fever in 3-36 month olds?
|
S pneumoniae
N meningitidis Ecoli |
|
|
What are the most common bacterial causes of fever in 3 years to adulthood?
|
S pneumoniae
N meningitidis Ecoli GAS |
|
|
What parts of a newborns immune system are inadequate?
|
T cell function
Ability to mount IgG response (also unable to contain simple infections) |
|
|
How do you do blood cultures?
|
Usually one is enough, ideally it would be from a separate venipuncture but this is weighed against the ability to do so.
|
|
|
What is the definition of UTI on UA?
|
Bacteriuria and pyuria
|
|
|
What is the threshold for a positive urine culture in cath? in clean catch?
|
Cath >10,000 CFU/mL
Clean catch >100,000 CFU/mL |
|
|
What are low risk criteria for bacterial meningitis (rate 0.1%)?
|
Children who have none of the following
+gram stain csf ANC >/= 1000 cells/uL csf protein >/= 80mg/dL peripheral blood ANC >/=10,000 cells/uL History of seizure before or at presentation |
|
|
What are contraindications to LP?
|
Cellulitis
Cardiopulmonary instability Bleeding diathesis Focal neuro deficits Signs of increased ICP |
|
|
How long after antibiotics does the csf become sterile?
|
Meningococcus 15min-2hour
Pneumococcal meningitis 4-10hours |
|
|
What is the rate of bacterial illness in children 0-28d presenting with fever >38
|
12%
|
|
|
In which neonates should you consider HSV?
|
Febrile infant with
-history of maternal genital herpes -fever and seizure -ill appearing -cutaneous vesicles on physical exam -evidence of transaminitis or coagulopathy |
|
|
What is the risk period for HSv?
|
2-12 days of life
|
|
|
What are noninfectious causes of septic appearing neonates?
|
Congenital adrenal hyperplasia with salt-wasting crisis
Undiagnosed ductal dependent congenital cardiac lesion |
|
|
What is a complete septic workup?
|
cbc
blood culture UA urine culture LP |
|
|
What is empirical treatment for 1-28d with r/p sepsis?
|
ampicillin
cefotaxime |
|
|
What should be done with ill appearing children of any age where sepsis is a possibility?
|
Complete septic w/u
admit to hospital empiric antibiotic therapy |
|
|
What are the Philadelphia criteria?
|
Age 29-60d
>/=38.2 no focus, well appearing wbc <15,000 neut <0.2 UA <10wbc, csf <8 wbc CXR negative Stool negative High risk -> admit Low risk -> home no antibiotics |
|
|
What are the Rochester criteria?
|
</=60d
>/=38 well, no focus wbc 5000-15000 Absolute band count <1500 Ua <10wbc Stool <5wbc (if done) Low risk-> home no antibiotics |
|
|
What are the Boston criteria?
|
Age 28-89d
>/=38 well appearing, no focus CSF<10wbc UA <10wbc wbc <20,000 CXR negative if obtained Home with antibiotics NPV 94.6 |
|
|
What % of children 0-6months with bacterial meningitis have classic meningeal signs?
|
27%
|
|
|
Why do we do less septic or partial septic work ups in children 3-36 months?
|
Since prevnar the rate of pneumococcal bacteria is so low that it is not cost-effective
|
|
|
Which infants still have a higher rate of pneumococcal bacteria despite preener?
|
3-6 months because they ahve not completed their primary series of vaccinations agains HIB and pneumococcus. Therefore test highly febrile children with >39 and no source
|
|
|
What is the algorithm for managment of febrile 3-36 months old?
|
If temp >39 and fully vaccinated then do UA +/- CXR
If temp >39 and incompletely vaccinated (missing 2,4,or 6 month) the ncbc, blood culture, UA, UCx +/- CXR (if wbc >20,000) |
|
|
At what age does the rate of occult bacteria decrease?
|
3 years
|
|
|
In what children is CA-MRSA more common?
|
wrestlers and football players
|
|
|
Which patients with skin abscesses should receive TMP-SMX (for CA MRSA)
|
Large abscesses (>5cm)
with cellulitis with fever |
|
|
When is the 2nd peak of meningococcal infection in childhood?
|
adolescents
|
|
|
What is appropriate initial therapy for meningococcal infection?
|
Ceftriaxone 100mg/kgIV divided q12hours
|
|
|
What is menacer?
|
Meningococcal conjugate vaccine
it decreases invasive disease by 67% and carriage rate by 66 % |
|
|
Define febrile seizure?
|
Brief
<15 minutes single non-focal or generalized tonic clonic |
|
|
Define complex seizure?
|
prolonged
recurrent (>1 in 24 hours) focal |
|
|
in which patients with febrile seizures should you strongly consider an LP?
|
<12 month
prior antibiotic therapy those with signs and symptoms worrisome for meningitis |
|
|
What is the differential diagnosis of fever and petechiae?
|
RMSF
meningococcal infection pneumococcal bacteremia strep pyogens viral illness ITP HSP leukemia |
|
|
What characterizes petechiae from vomiting?
|
Above the nipple line
|
|
|
Why do you need to diagnose Kawasaki?
|
To investigate for coronary artery aneurysm
|
|
|
What is the treatment for suspected KD?
|
IVIG
ASA echoq |
|
|
What are focal infections specific to CA patients?
|
typhlitis
stomatitis |
|
|
What is appropriate monotherapy for febrile neutropenia?
|
Cefepime
|
|
|
What is the most common cause of sickle related deaths?
|
infection
~40% of SCD related deaths |
|
|
Which SCD patients require penicillin prophylaxis
|
<5years
|
|
|
Which organisms typically cause endocarditis?
|
s aureus
s viridans s bovis enterococci Haemophilus actinobacillus cardiobacteria eikenella Kingella (HACEK) |
|
|
What is the risk of SBI in infants </=3months and what are the most common illnesses?
|
Between 6-10%
UTI Bacteremia Meningitis |
|
|
Define occult bacteremia?
|
The presence of pathogenic bacteria in the blood stream of a well appearing febrile child in the absence of a focus of infection. The term typically refers to children 3-36 months of age.
|
|
|
What bacterial organisms commonly cause VP shunt infection?
|
S aureus
S epidermidis |
|
|
What is the most common cause of functional obstruction of the upper airway?
|
The tongue
|
|
|
What are the presentations of upper airway pathology?
|
Acute infections
Undiagnosed congenital anomalies Upper airway obstruction from a FB |
|
|
What is stridor?
|
The sound resulting from partial airway obstruction between the nose and suprasternal trachea
|
|
|
What are optimal conditions for a lateral neck X-ray?
|
Childs head in extension
film taken during inspiration |
|
|
What are supraglottic congenital lesions?
|
choanal atresia
macroglossia micrognathia thyroglossal duct cyst lingular thyroid |
|
|
What are acquired causes of supraglottic airway disease?
|
Nasal FB
Nasal polyp Hypertrophic tonsils and adenoids epiglottitis peritonsilar abscess retropharyngeal abscess pharyngitis mononucleosis upper airway FB |
|
|
Which form of choanal atresia may present to the ED?
|
Unilateral because bilateral is life threatening and identified shortly after birth
|
|
|
What conditions are associated with macroglossia?
|
Downs
Congenital hypothyroidism Glycogen storage disease |
|
|
What conditions are associated with micrognathia
|
Pierre Robin
Treacher-Collins |
|
|
At what spinal levels is the retropharyngeal space found?
|
Base of the skull to T2
|
|
|
In what age group is RPA seen?
|
<3 years
|
|
|
What are signs and symptoms of RPA?
|
fever
sore throat neck stiffness/nuchal rigidity torticollis trismus neck swelling drooling stridor |
|
|
What is the normal width of the soft tissues on a lateral neck X-ray?
|
The width of the retropharyngeal space should not exceed the diameter of the adjacent vertebral body
|
|
|
What is the current epidemiology of epiglottitis?
|
Average age 80 months (3-7year of age)
group A strep S aureus S pneumo |
|
|
What should raise suspicion for epiglottitis in adolescents?
|
Severe odyno or dys-phagia in the absence of signs of pharyngeal swelling, erythema or exudates
|
|
|
What are signs of epiglottitis on X-ray?
|
Thumbprint sign (enlarged epiglottis)
Thickened aryepiglottic folds lack of air in the vallecula dilated hypopharynx |
|
|
What are congenital lesions of the larynx?
|
Laryngomalacia
Laryngeal web Vocal cord paralysis Congenital subglottic stenosis Laryngeal cyst Subglottic hemangioma Laryngotracheoesophageal cleft |
|
|
What virus accounts for most viral croup?
|
Parainfluenza
|
|
|
What is the pathophysiology of croup?
|
Inflammation, exudate and edema of the mucosal and submucosal tissues of the subglottic space
|
|
|
What is mild croup?
|
Intermittent barky cough
Stridor with agitation Mild tachypnea and tachycardia |
|
|
What is moderate croup?
|
Stridor at rest worsened by agitation
Barky cough Increased work of breathing |
|
|
What is the X-ray finding in croup?
|
Steeple appearance of subglottic trachea
|
|
|
What are the benefis of steroids in moderate croup?
|
Faster improvement in hospitalized patients
Decreased incidence of intubation Higher >lower dose |
|
|
What are the benefits of steroids in mild croup?
|
improves symptoms
decreased need for return to medical care |
|
|
What is the onset and duration of racemic epinephrine?
|
10 min onset
1-2 hour duration |
|
|
Which patients with moderate croup who receive eli can be discharged?
|
-2 hours of observation post-epinephrine
-absence of stridor or retractions -access to f/u care |
|
|
What are indications for admission of croup?
|
Severe respiratory distress/failure
Unusual symptoms (hypoxia or hyperpyrexia) dehydration persistent stridor post epi and steroids persistent tachycardia and tachypnea Complex past medical history |
|
|
What % of croupers require intubation?
|
1-2%
|
|
|
What are congenital lesions of the trachea?
|
Tracheomalacia
Tracheal stenosis (complete tracheal rings) Vascular ring Mediastinal masses |
|
|
What is bacterial tracheitis?
|
A secondary bacterial infection complicating a pre-existing viral infection
|
|
|
What are features that suggest bacterial tracheitis?
|
Viral prodrome followed by acute decompensation
Atypical symptoms for croup (high fever, cyanosis, severe distress) Poor response to treatment Inspiratory and expiratory stidor |
|
|
What is the peak age of croup, epiglottitis and bacterial tracheitis
|
Croup - 6months->3year
Epiglottitis 3-7 year Bacterial tracheitis 3-5 years (but seen throughout childhood) |
|
|
What are features of severe croup?
|
Abnormal mental status
Stridor at rest Fatigue Hypoxia Hypercapnia |
|
|
What is spasmodic croup?
|
Sudden onset of severe stridor and a barky cough without a viral prodrome, associated with allergy and GE reflux. Unclear how to differentiate this from croup
|
|
|
Describe laryngomalacia?
|
The most common cause of chronic stridor in infants
-caused by the incomplete development of supporting cartilage in the larynx Most resolve by the age of 2 |
|
|
What is a vascular ring?
|
Anomaly of the aortic arch; related to vessles in which a ring is formed that encircles the trachea, esophagus or both
|
|
|
What is the procedure for FB in the hospital
|
Call ENT/Anesthesia
Jaw thrust If no chest rise/resp then assist ventilation with BVM If still no chest rise, laryngoscopy to remove FB If no FB seen and suspicion of esophageal FB continue back blows and Heimlich If FB in airway but can't get out attempt to push into main stem bronchus Emergency needle croc |
|
|
What level of hyperbilirubinemia is associated with the development of jaundice?
|
Total bilirubin >/=86umol/L
|
|
|
What is the presentation of kernicterus?
|
Poor feeding, high-pitched cry, lethargy, muscular rigidity, opisthotonus, seizure, death
|
|
|
What are indications for workup in jaundiced infants?
|
Sick-appearing infant
Jaundice appearing within 24 hours of birth Elevated conjugated bilirubin Rapidly rising total serum bilirubin unexplained by Hx and Pe. Total serum bilirubin approaching exchange level or not responding to phototherapy Jaundice persisting beyond 3 weeks |
|
|
What is the differential for unconjugated hyperbilirubinemia in infants?
|
Benign physiologic (physiologic or breast milk)
Hemolysis Infectious (TORCH, UTI, Sepsis) Obstructive (meconium ileus, Hirschsprungs, duodenal atresia, pyloric stenosis) Metabolic (galactosemia, congenital hypothyroid, crigler najjar, Gilberts) |
|
|
What is the differential for conjugated hyperbilirubinemia?
|
Infectious (TORCH, UTI, Gram -ve sepsis, listeriosis, tuberculosis, viruses, varicella, coxsackie, HIV, HBV)
Obstructive (Biliary atresia Choledocal cyst Bile duct strictures Neonatal hepatitis Congenital hepatic fibrosis) Metabolic/Genetic |
|
|
What is Reye's syndrome?
|
A potentially fatal disease that affects primarily the brain and liver and also causes hypoglycaemia. Associated with ASA consumption. Causes a fatty liver severe encephalopathy
|
|
|
What is the differential of the double-bubble sign?
|
Pyloric stenosis
Duodenal atresia Malrotation with midgut volvulus |
|
|
What is the epidemiology of midgut volvulus?
|
75% in the first month of life and 90% in the 1st year of life
|
|
|
What is the presentation of midgut volvulus?
|
sudden onset bilious emesis +/- abdo
|
|
|
When do the majority of midgut volvulus present?
|
90% within the first year of life
|
|
|
What are the findings of midgut volvulus on X-ray?
|
abnormal position of the duodenal c-loop and small bowel with a characterisitc corkscrew appearance
|
|
|
What is the treatment for malrotation with midgut volvulus?
|
Emergency surgery consultation
NPO and NGT IV fluids Triple antibiotic coverage |
|
|
When does necrotizing enterocolitis develop?
|
In the 1st week of life in term infants ( those mostly affects infants that are premature)
|
|
|
What are the three stages of NEC and their xray findings?
|
STAGE 1 - suspected NEC -> dilated loops of bowel, asymmetric pattern of bowel gas
STAGE 2 ->definite NEC as proven by abdominal radiographs-> pneumatosis intestinalis or gastrulas, portal vein gas STAGE 3->advanced NEC with perforation => advanced NEC with perforation |
|
|
What is antibiotic coverage for NEC or malrotation with midgut volvulus?
|
Triple antibiotic coverage
Ampicillin and gentamicin plus clinda or metronidazole |
|
|
What is the best modality to diagnose intusussception
|
Ultrasound which shows a complex mass with a multilayered or rolled appearance
|
|
|
What is the success rate for air or barium enema treatment of intusussception?
|
90% though may recur in ~10%
|
|
|
What is the presentation of Hirschsprungs?
|
Failure to pass mecomium in the nursery.
May present to the ED with chronic constipation, poor weight gain and FTT |
|
|
What is the treatment for Hirschsprungs?
|
Decompression with a rectal tube, urgent surgery consultation, definitive treatment is surgical resection
|
|
|
What are the types of diarrhea?
|
Secretory - absence of reduction in stool volume with fasting
Osmotic - presence of poorly absorbed solutes in colon due to altered bacterial flora, damage to mucosa or ingestion of substance Dysentry: diarrhea with blood Diarrhea due to altered motility: increased or decreased transit time |
|
|
What physiologic factors predispose children to more severe complications of infectious diarrhea?
|
Large ECF compartments compared with adults
Limited stores of metabolic substrates such as fat and glycogen Limited ability to access fluids |
|
|
What characterizes mild dehydration?
|
May have Dry mucous membranes
Normal skin turgor Alert Normal anterior fontanelle no sunken eyeballs normotensive Cap refill </=2sec small urine volume |
|
|
What characterizes moderate dehydration?
|
Dry mucous membranes
may have reduced skin turgor irritable sunken eyeballs orthostatic hypotension cap refill >2sec oliguria elevated BUN and SG |
|
|
What characterizes severe dehydration?
|
Dry mucous membranes
reduced skin turgor depressed fontanelle lethargic sunken eyeballs hypotension (orthostatic) increased pulse anuria cap refill >2sec very high BUN acidemia |
|
|
What are common causes of vomiting?
|
CNS infections or space occupying lesions
GI - obstruction, peritonitis, hepatitis, liver failure, appendicitis, pyloric stenosis, midgut volvulus Drug - ingestion, OD, drug effect Endocrine - addisonia crisis, DKA, CAH Renal - UTI, pyelonephritis, renal failure, RTA Cardiac - CHF Infection |
|
|
What is the choice of IV fluids and duration of replacement for each type of dehydration?
|
Isonatremic - D5W 0.45% NS over 24 hours
Hyponatremic - D5W NS over 24 hours Hypernatremic D5W0.45%NS over 48 hours |
|
|
What is the treatment for hyponatremic seizures?
|
4cc/kg 3%NaCL over 10 minutes
|
|
|
What is the management of phimosis?
|
Unless vascular compromise or urinary outlet obstruction
Gentle retraction, good hygiene and topical betamethasone for 6 weeks |
|
|
What is the epidemiology of testicular torsion?
|
It can occur at any age, it is most common during adolescence, peaks at age 13
|
|
|
What is the clinical presentation of testicular torsion?
|
Acute scrotal pain and swelling
elevated testicle typically an absence of the cremasteric reflex (light stroking of the superior and medial part of the thigh results in contraction of the cremaster muscle that pulls up the scrotum and testis on the side stroked) |
|
|
What should be done if suspicion for testicular torsion is high but your suspicion is high?
|
scintigraphy
|
|
|
What is the first step in suspected torsion if onset within 12 hours?
|
Urology consult for immediate surgical exploration
|
|
|
When should manual detorsion be attempted?
|
If delay to urologic care and pain ongling for <24 hours
Done by rotating from medial to lateral |
|
|
What is the epidemiology of varicocele?
|
It is rare in children <10years of age
|
|
|
What are the risks associated with varicocele?
|
If untreated, especially when large it may cause long term decrease in sperm and testosterone production
|
|
|
What is the management of varicocele?
|
Urology referral
|
|
|
What are the etiologies of testicular tumours?
|
Primary vs Metastatic (Lymphoma, leukemia)
|
|
|
What is the treatment of UTI in children >2years of age?
|
If not toxic, can treat as outpatient
Simple cystitis ->TMP-SMX for 3 days Pyelonephritis -> TMP-SMX for 14 days. |
|
|
What is the etiology of hypertension in children?
|
Primary - Essential
Secondary Renal (glomerulonephritis, HSP, pyelonephritis, obstruction or reflux, polycystic kidney disease, diabetic nephropathy, trauma, renal transplant or hemodialysis, tuberous sclerosis, systemic lupus nephritis) Endocrine (pheochromocytoma, Cushing's, CAH, corticosteroid treatment, hyperthyroidism, neuroblastoma, ovarian tumor) Cardiac (CHF, coarctation of the aorta) Vascular (HUS, Kawasaki, Renal artery thrombosis or stenosis) Neurologic (CNS tumor or infection, CNS trauma or abuse, increased ICP, GBS) Neoplastic (neuroblastoma, adrenal carcinoma) Drugs (corticosteroids, cocaine, symptathomimetics, OCP, phencyclidine, beta blocker, lead, mercury) Iaotrogenic |
|
|
What are the medications used in hypertensive emergencies?
|
Nitroprusside
Hydralazine Labetalol Esmolol Phentolamine |
|
|
Why can asthma be worse in children?
|
A small decrease in the internal diameter of the airway can cause a significant decrease in the cross-sectional area
A compliant chest and horizontal ribs limit the use of the thorax to increase TV (MV is rate dependent) Abdominal distention impedes diaphragmatic breathing |
|
|
What are indicators of poorly controlled asthma?
|
Frequent exacerbations
Frequent ED visits for asthma Frequent hospitalizations to the ward or ICU |
|
|
When should supplemental oxygen be given to a wheezing child?
|
SpO2<92%
|
|
|
What does a normal PaCo2 in severe asthma reflect?
|
Impaired ventilation and impending respiratory failure
|
|
|
Is PEFR useful in kids with asthma?
|
Many children are not able to co-operate with PEFR measurement especially moderate to severely ill children
|
|
|
Which children with wheezing should have a chest X-ray?
|
Focal chest findings
Fever Extreme distress History of choking |
|
|
What is the differential diagnosis for asthma in children?
|
Infection (bronchiolitis, croup, pneumonia, TB, bronchiolitis obliterans)
Anatomic (GE reflux, CF, TEF, CHF, mediastinal mass, vascular ring) Acquired (FB aspiration, anaphylaxis) |
|
|
What characterizes mild asthma?
|
PEFR >70% of personal best
|
|
|
What amount of nebulized SABA is delivered to the small airways?
|
10%
|
|
|
When can a mild asthma exacerbation be discharged?
|
Those sustaining clinical improvement 60min after the most recent SABA treatment
|
|
|
Which patients should have inhaled corticosteroids at discharge?
|
-frequent asthma symptoms
-night time awakenings -frequent SABA for asthma control |
|
|
What are features of a moderate asthma exacerbation?
|
-tachypnea
-wheezing throughout expiration -significant accessory muscle use -SpO2 92-95% PEFR 41-70% personal best |
|
|
Should ipratropium bromide be given to pediatric patients with asthma exacerbation?
|
It should be standard treatment for children with moderate to severe exacerbation
|
|
|
Is there a difference in oral vs IV steroids?
|
No the guidelines recommend oral
|
|
|
Should you give dexamethasone or prednisone for asthma?
|
Either, the dose of dex is 0.6mg/kg with the option for one additional dose at home (compared to 4 for pred)
|
|
|
What characterizes a severe asthma exacerbation?
|
Restlessness, lethargy, extreme tachypnea or tachycardia, Significant use of accessory muscles
SpO2 <92% PEFR <40% personal best |
|
|
What mode of SABA delivery may be needed in severe asthma?
|
SC or IM terbutaline or epi
terbutaline (1mg/mL) 0.01 mL/kg/dose epi 0.01 mL/kg/dose SC or IM |
|
|
What is the dose of IV terbutaline?
|
10ug/kg bolus over 10 min
0.1-0.3ug/kg/min |
|
|
What treatment can be considered in moderate to severe asthma?
|
MgSo4
IV SABA (only in impending respiratory failure) Heliox (only in severely ill) |
|
|
What is the advantage of heliox?
|
Low density therefore less turbulent flow and decreased likelihood of ventilatory failure
|
|
|
What mechanical ventilatory strategy is used for asthmatic patients intubated?
|
permissive hypercapnia
minimize TV and RR in order to minimize peak pressures |
|
|
What are CXR findings of asthma?
|
Hyperinflation
Atelectasis Interstitial markings PTX |
|
|
What is the pediatric dose of albuterol by MDI?
|
<20kg 4 puffs
>20kg 8puffs |
|
|
What is the IV dose of methylprednisolone in children?
|
1-2mg/kg (max 125mg)
|
|
|
Should methylxanthines or aminophylline be used in children with asthma?
|
No
|
|
|
What is the epidemiology of bronchiolitis?
|
Children <2 years
|
|
|
What is the etiology of bronchiolitis?
|
RSV is the most common
|
|
|
What is the management of mild bronchiolitis
|
nasal suction
consider SABA trial If improved continue SABA and dc home If not improved decide on disposition and discontinue SABA |
|
|
What characterizes mild bronchiolitis?
|
Normal feeding
spo2 >95% <60 no to minimal retractions no accessory muscles no to minimal wheezing good air exchange |
|
|
What is the management of moderate to severe bronchiolitis?
|
Consider supplemental oxygen
Consider the need for hydration SABA trial If improved continue SABA and ***** for disposition If not improved discontinue SABA and admit to hospital. Consider nebulized epi. |
|
|
What factors are associated with a more severe clinical course of bronchiolitis and may mandate hospitalization (9)?
|
Age <3 months
Gestational age <34 weeks Ill appearance Hypoxemia (<95%) Tachypnea (>70/min) Significant atelectasis on CXR History of hemodynamically significant congenital heart disease Chronic lung disease Immunocompromised state |
|
|
What is the treatment of pediatric pneumonia in 0-3 months?
|
Ampicillin and cefotaxime
|
|
|
What is the treatment for pertussis in peds?
|
Erythromycin estolate
|
|
|
What are the pathogens in pediatric pneumonia 0-3 months?
|
GBS
Gram negative bacilli (Listeria) |
|
|
What are the pneumonia pathogens in 3mo-4 years?
|
S pneumoniae
H influenzae Staph aureus GAS Neisseria |
|
|
What is the outpatient treatment of pneumonia in 3mo-4 years?
|
High dose amoxicillin (outpatient)
Cefotaxime (inpatient) |
|
|
What are common pathogens in pneumonia 5years -adolescents?
|
M pneumoniae
C pneumoniae |
|
|
What is the treatment of pneumonia in 5years to adolescents?
|
Erythromycin, azithromycin or clarithromycin (outpatient)
Cefotaxime and macrolide (inpatient) |
|
|
What are complications of pediatric pneumonia?
|
Dehydration
Bacteremia Apnea Respiratory failure Pleural effusion Lung abscess Empyema Pneumatocele Pneumothorax |
|
|
What are non-infectious techniques that may present as pneumonia?
|
Radiologic technique (inadequate inspiration, breast shadow, thymus, uneven grid on film, under penetrated)
Primary pulmonary (asthma, brochiectasis, atelectasis, bronchopulmonary dysplasia, cystic fibrosis, pulmonary sequestration, congenital cystic malformation, alpha antitrypsin deficiency) Aspiration (FB, chemical) Primary cardiac (CHF, CHD) Pulmonary infarction (sickle cell vaso-occlusive, PE) Collagen vascular disorders ARDS Pleural effusion Neoplasm |
|
|
What are the 3 clinical stages of pertussis?
|
Catarrhal 1-2 weeks
Paroxysmal 2-4 weeks Convalescent 2-4 weeks |
|
|
How effective is the pertussis vaccine?
|
Only 80% effective after 3 doses
|
|
|
What is the culture technique for pertussis?
|
From nasopharyngeal secretions it may be negative in the 1st week and after the 4th week. PCR is more sensitive and specific
|
|
|
What is the treatment for pertussis?
|
Erythromycin (antibiotics have no effect on disease progression after the paroxysmal stage but may be beneficial because they limit the spread of organism)
|
|
|
What are complications of pertussis?
|
Apneic episodes, seizures, secondary bacterial pneumonia, encephalopathy, death
|
|
|
What is the antibiotic treatment for children with aspiration pneumonia?
|
Must cover anaerobes
(Amoxicillin and clindamycin) If seriously ill then consider metronidazole or cefoxitin |
|
|
What is the antibiotic treatment for pneumonia in patients with CF?
|
Must cover pseudomonas (ticarcillin/clavulanic acid or pip-tazo and amino glycoside. Consider imipenem or meropenem if resistant
|
|
|
Explain fetal circulation of oxygenated blood?
|
Oxygenated blood from the placenta -> umbilical vein ->ductus venosus (bypassing the liver)-> IVC->RA-> foramen oval->LA->LV->aorta->body
|
|
|
Explain fetal circulation of de-oxygenated blood?
|
SVC->RA->RV->pulmonary artery->ductus arteriosus->descending aorta->umbilical arteries->placenta
|
|
|
When does the foramen ovale close?
|
3 months
|
|
|
When does the ductus arteriosus close?
|
functionally at 10-15hours
anatomically at 2-3 weeks |
|
|
How do infants increase cardiac output?
|
They cannot increase contractility. They first respond by increasing HR then increasing SVR with cool, pale, mottled skin, delayed cap refill and weak distal pulses
|
|
|
Differentiate peripheral and central cyanosis clinically?
|
Peripheral: involves the hands and feet (acrocyanosis)
Central involves the lips, tongue and mucous membranes |
|
|
What are cardiovascular, pulmonary and hematologic causes of central cyanosis?
|
Cardiovascular: cyanotic CHD with right to left shunts, arteriovenous fistulae (peripheral, hepatic, cerebral)
Pulmonary: bronchiolitis, pneumonia, pulmonary edema hematologic methemoglobinemia, sulfhemoglobinemia, mutant hemoglobins with low oxygen affinity |
|
|
What are common presenting signs and symptoms of cardiac disorders in infants and children?
|
General (fussiness, lethargy, poor feeding, poor growth)
Respiratory (respiratory distress, wheezing, apnea) Cardiovascular (tachycardia, shock, pallor, mottling, cyanosis, palpitations, chest pain, syncope, various dysrhythmias) |
|
|
What clues help distinguishes between cardiac and pulmonary etiologies of central cyanosis?
|
Respiratory status (in cardiac they are comfortably blue and in pulmonary they are in resp distress)
Response to crying: worsening cyanosis in cardiac and improved cyanosis in pulmonary Response to oxygen: minimal to no improvement in cardiac and improvement in pulmonary |
|
|
What is the differential of chest pain in hi child?
|
Pulmonary - asthma, pneumonia, PE
Cardiovascular (aortic dissection, myocardial ischemia in the context of CHD, drug use) GI (gastritis, GERD) MSK (chest wall pain, costochondritis, precordial catch syndrome) |
|
|
What are pathologic features of a cardiac murmur (7)?
|
Diastolic murmur
Systolic murmur louder than 3/6 (continuous or associated with a thrill) abnormal heart sounds cyanosis or respiratory distress bounding pulses or weak pulses ECG abnormalities Abnormal CXR |
|
|
What are the 2 most common innocent murmurs in pecs?
|
Pulmonic flow murmur due to relatively thin walls and angulation of the pulmonary arteries at birth. left upper sternal border with radiation throughout the entire chest, axilla and back
usually disappearas at 3-6 months Stills murmur systolic murmur resutls from turbulent flow 2-6 years best heard along the left midsternal border vibratory/musical quality increased intensity with fever, excitement, exercise or anemia |
|
|
What is the hyperoxia test?
|
Bedside diagnostic test to differentiate between pulmonary and cardiac causes of central cyanosis: assess the rise in arterial oxygenation with administration of 100%O2. >250mmHg excludes CHD
<100mmHG strongly suggestive of CHD 100-250mmHg may indicate CHD with intracardiac mixing |
|
|
What can be seen on the CXR from birth until 5 years?
|
Thymus with wavy borders creating the classic sail sign along the superior right heart border
|
|
|
What are the 3 classic cardiac silhouettes that can be seen in patients with CHD?
|
Boot shaped -> tetralogy of fallot
Egg on a string -> transposition of the great vessels Snowman shaped or figure or eight heart -> total anomalous pulmonary return |
|
|
What differences are expected in a pediatric ECG as compared to an adult ECG?
|
Faster resting heart rate
right axis deviation (up to 2 months) Shorter PR and QRS intervals Longer QTc Juvenile T-wave pattern with flat or inverted T waves in V1 to V3 (may persist until adolescence) |
|
|
What is the incidence of CHD?
|
~1%
|
|
|
What are the most common acyanotic anc cyanotic CHD?
|
Acyanotic -> VSD 25% of CHD
Cyanotic -> TOF 10% of CHD |
|
|
What fluid boluses should be given when CHD is suspected?
|
10mL/kg to prevent fluid overload
|
|
|
Which CHD can present late?
|
Tetralogy of Fallot (birth to 12 weeks)
|
|
|
What are the cyanotic congential heart diseases (5 Ts)
|
Tetralogy of Fallot
Transposition of the great arteries Tricuspid atresia Truncus arteriosus Total anomalous pulmonary venous return |
|
|
What congenital heart diseases are ductal dependent?
|
Require PDA to preserve blood flow from the aorta to the pulmonary circulation:
Tetralogy of Fallot Tricuspid atresia Pulmonary atresia Hypoplastic right heart Transposition of the great vessels Requiring PDA to preserve blood flow from the pulmonary artery to the systemic circulation Severe coarctation Severe aortic stenosis Hypoplastic left heart syndrome |
|
|
What are the adverse effects of PGE1 infustions
|
Apnea
Bradycardia Hypotension Flushing Seizures Decreased platelet aggregation |
|
|
What are the 4 anatomic abnormalities associated with Tetralogy of Fallot?
|
Right ventricular outflow tract obstruction
Right ventricular hypertrophy Overriding aorta (receives blood flow from both ventricles) VSD |
|
|
Explain the physiology of blood flow in Tetralogy of Fallot?
|
Some of the deoxygenated blood in the RV is shunted across the VSD into the LV. This deoxygenated blood mixes with the well oxygenated blood from the lungs. When the SVR (as occurs during a tet spell, more deoxygenated blood from the RV is shunted across the VSD resulting in hypoxia, metabolic acidosis and worsening cyanosis
|
|
|
What is a tet spell
|
Period of hyperpnea, uncontrollable crying and worsening cyanosis occuring commonly in infants 2-4 months
Triggers: hypovolemia, tachycardia or any event that suddenly decreases SVR such as crying or defecation. |
|
|
What is the management of a tet spell?
|
-knee to chest position to increase SVR and decrease right to left shunt
-supplemental oxygen -morphine or fentanyl -sodium bicarb consider ketamine 1-2mg/kg IV |
|
|
What conditions are associated with an increased risk of severe or fatal RSV infections?
|
Cyanotic or complex congenital heart defects
|
|
|
What is the management of a tet spell?
|
-knee to chest position to increase SVR and decrease right to left shunt
-supplemental oxygen -morphine or fentanyl -sodium bicarb consider ketamine 1-2mg/kg IV |
|
|
What conditions are associated with an increased risk of severe or fatal RSV infections?
|
Cyanotic or complex congenital heart defects
|
|
|
Define trachemalacia?
|
a condition of abnormally weak tracheal walls due to the loss of the supporting cartilage and structural integrity
|
|
|
What are the types of tracheomalacia?
|
Congenital
Extrinsic (vascular ring) Intrisic (post prolonged intubation) |
|
|
What is the presentation of tracheomalacia?
|
stridor in the setting of viral URTI
|
|
|
What is the treatment for tracheomalacia?
|
Supportive
Racemic epi Admit if severe symptoms |
|
|
what are the main reasons children with trach tubes visit the ED?
|
Exacerbation of their pulmonary disease
blockage of the tube with a mucous plug Equipment failure |
|
|
What is the management of trach tube obstruction?
|
attempt assisted ventilation with high concentration of O2
suction change tube ventilate through the stoma transport to specialized care centre |
|
|
How do you manage trach dislodgement?
|
replace trach
provide assisted ventilation with high Fio2 through stoma transport to specialized centre |
|
|
What should you do if you are unable to re-insert a trach tube?
|
Use a size smaller
try using the same size as the old one ventilate through the childs mouth while blocking the stoma |
|
|
How do you manage a child with pacemaker failure?
|
assess heart rate and perfusion
treat for shock follow PALS transfer to specialized centre |
|
|
How do you manage child with central venous line and suspected air embolism?
|
clamp the line
place patient on left side with head down high flow oxygen transfer |
|
|
How do you manage PEG or PEJ dislodgement?
|
If <3mo -> consult GI as track may not have been formed yet and reinsertion can create false track
If >3 mo-> re-insert using smaller tube or foley |
|
|
How would you confirm PEG or PEJ tube placement?
|
instill gastrograffin 15-30cc in the tube and do an abdo AP and lateral to observe the tube an dye in the stomach
|
|
|
What should you suspect in a patient with CP that presents with AMS or resp depression?
|
Ask about the presence of a baclofen pump
|
|
|
Explain why baclofen pumps are used?
|
GABA agonist used in cerebral palsy to treat spasticity; the pump is implanted under the abdominal wall and connected to the thecal sac surrounding the spinal cord. Binds to receptors in the spinal cord thereby inhibiting spinal reflexes
|
|
|
What are 2 problems associated with baclofen pumps?
|
Od secondary inappropriate dosing or machine programming
Withdrawal secondary to machine failure |
|
|
what is the management of baclofen OD?
|
stop pump. If not possible empty the reservoir with a 22 GA needly by inserting the needle in the centre of the pump
|
|
|
What is the presentation of baclofen withdrawal?
|
they present with increased spasticity, tachycardia, blood pressure chages, severe hyperthermia, rhabdo progressing to multiorgan failure and death
|
|
|
What is the most common allergy in patients with spina bifida?
|
latex
|
|
|
How would VP shunt infection present?
|
Fever
Ill appearing AMS Hyperthermia and tenderness over shunt tubing in the scalp abdo pain and tenderness vomiting |
|
|
What are the most common organisms in VP shunt infections?
|
Staph epi
Staph aureus HIB (rare) |
|
|
What are complications of VP shunt?
|
Shunt tract infection
peritonitis shunt fracture shunt obstruction or malfunction |
|
|
What is the management of obstructed PEG tubes?
|
Inject coca cola
proteolytic enzymes if still obstructed -> change the tube |
