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544 Cards in this Set
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What is the most common cause of gastroenteritis?
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Viruses (70%)
Rotavirus is the most common viral cause 2. Astrovirus 3. Norwalk virus |
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What are the clinical features associated with viral gastroenteritis? What about bacterial gastroenteritis?
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Viral enteritis
* Associated with URTIs * Resolves in 3-7 days * Slight malaise, fever, vomiting, vague abdominal pain Bacterial * severe abdominal pain * high fever * bloody diarrhoea RF: travel, poorly cooked and refrigerated foods |
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What questions do you need to ask in a history from a child with suspected gastroenteritis?
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* Vomiting - frequency, colour, bile, blood, triggers
* Stool output - no. blood, mucous, watery * Intake - how much and type of fluid * Urine output - no. of wet nappies * lethargy, drowsiness * weight loss or poor growth * duration of illness * Infected contacts * FHx * Repeated presentations of same/similar symptoms * Previous illnness (e.g., short gut, renal insufficiency, heart disease) |
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What conditions do you need to exclude in someone who comes in with vomiting and diarrhoea?
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* Sepsis - meningitis, UTI
* Pneumonia * Metabolic - DKA * Surgical abdomen - intussuception, appenditicitis * IBD - ulcerative colitis * Haemolytic uraemic syndrome |
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What are the signs of a child with severe dehydration?
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* Reduced skin turgor
* Sunken fontanelle and eyes * Delayed capillary refill time > 3 secs * Tachycardia * Weak, rapid breathing * poor perfusion * hypotension * shock |
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What investigation should you order in someone with suspected gastroenteritis?
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If mild dehydration - none
If moderated to severe dehydration - EUC, FBC, BSL, Stool micro, culture, virology NB: EUC is essential in any child having IV fluid If considering other aetiologies: - UA - Blood culture if temp > 38.5 - X rays - AXR, CXR, US, air enema |
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When are antibiotics indicated in gastroenteritis?
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- Neonate with severe salmonella or signs of sepsis
- strongyloides stercoralis - Shigella dysentery |
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When do you give rehydration fluids in IV fluid therapy?
What is the formula for rehydration fluids? Which fluid should be given? |
Give rehydration fluids if moderate dehydration
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5/100 x wt (kg) x 1000 = mls/24 hours
N/2 saline |
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What is the fluid regime for severe dehydration?
What type of fluids? |
Bolus 10-20ml/kg - stat - NS
Rehydration 5 x wt x 10 - per 24 hours - N/2 Maintenance 4:2:1 - per hour - N/2 might need to add glucose |
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How long can fluids be ordered for?
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maximum 24 hours
Must be reassessed at least every 24 hours after review of clinical/electrolyte status |
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What adivce would you give to a childcare centre about managing outbreaks of gastroenteritis?
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1. Vigilant handwashing
2. Be on the lookout for signs of acute dehydration (sleepy, lethargy, dry lips and mouth) 3. First signs of gastro - send child home - tell parents not to bring back children until they are completely well |
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How do you monitor rehydration?
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- Weigh patients 6 hourly
- Re-assess after 4-6 hours then 8 hrly after that - Clinical signs of dehydration - Urine output - Ongoing losses - Signs of fluid overload |
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What history do you want to know in an infant < 3 months with a suspected UTI?
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Most common
- Fever - Vomiting - Lethargy - Irritability - Poor feeding - FTT |
Less common
- Abdominal pain - Jaundice - haematuria - offensive urine |
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What history do you want to know in an older child with a suspected UTI?
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- Dysuria
- Frequency - Abdo/loin pain - Wetting - Haematuria - Fever - Vomiting - Malaise |
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What is the best method for obtaining urine for a UA sample?
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Suprapubic aspiration = gold standard
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Other methods:
- Catheter samples - clean catch - urine collection pads |
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What features in a urine sample would lead you to think that it is contaminated?
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Skin contamination: squamous epithelium
Specific gravity > 1.037 If micro organsisms are present but no pyuria (pus) Growth of more than one organism |
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What can full ward test (dipstick) urine test for?
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- urinary protein
- blood - nitrites (produced by bacterial reduction or urinary nitrite) - leucocyte esterase (an enzyme present in WBCs) |
NB: FWTs are a screening test only
If you really suspect UTI - send a specimen for micro and culture |
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Are nitrites sensitive or specific for UTI?
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Sensitivity no - not all organisms produce nitrites and nitrites take time to develop in urine
Specific no - They may appear in other infections |
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Is pyuria (leucocyte esterase) sensitive for UTI?
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No - not all patients with UTI have pyuria (especially the very young and neutropenic)
Leucocyte esterase can only be detected with relatively high WBC counts in urine |
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Are leucocytes specific for UTI?
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No - leucocytes appear in the urine in many other febrile illnesses
Local sources (vagina, foreskin) can contaminate the urine |
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What tests need to be done in in young children after their first UTI? Why?
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Renal ultrasound
- during acute infection if < 6 months and recurrent UTI - within 6 weeks if typical UTI and < 6months or if > 6 months and recurrent UTI Micturating cysto-urethrogram (MCU) - < 6 months if recurrent UTI - consider if > 6 months and recurrent UTI DMSA - nuclear medicine renal scan - uses technetium-99m - If recurrent UTI (regardless of age) US - structural abnormalities (size, cysts, dilation, stones) and urinary tract obstruction e.g., hydroureter, dilated pelvis, DMSA - evaluates function, size, shape and position of the kidneys and detects scarring caused by frequent infections MCU - contrast instilled into bladder - patient voids - visualises bladder surface and urethra, vesicoureteric reflux, and obstruction |
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What is the treatment of a UTI?
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if afebrile (cystitis)
- cephalexin or bactrim (oral) - 3 days If febrile (p/n) - cephalexin or bactrim (oral) - 7 days If < 1 month old or very unwell - ampicillin and gentamicin (IV) - until appropriate to switch to oral |
Check antibiotic sensitivities and adjust therapy in 24-48 hours
Change to oral antibiotics after 3-4 days of IV (Augmentin, co-trimoxazole, trimethoprim) |
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Differential diagnosis of UTI?
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Meningitis
** need more options |
Any child who us unwell should be admitted for IV antibiotics, include blood cultures, electrolytes and consider an LP
Just because you have found evidence of a UTI does not exclude another serious infection (e.g., meningitis) 2% of children will have asymptomatic bacteruria - this may not be the cause of their acute presentation. Also organisms may spread from UT to elsewhere DO NOT omit a LP in a sick child just because you have found a UTI |
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What preventative methods can you suggest to parents who want to avoid their kids getting another UTI?
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Regular fluids and voiding
Avoid/treat constipation Avoid caffeinated drinks Cranberry supplements Correct wiping |
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What preventative methods can you suggest to parents with kids with known vesicoureteric reflux to avoid UTI?
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Circumcision in boys
Prophylactic antibiotics Surgery (re-implantation, deflux or other injection) |
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What are the signs and symptoms of bronchiolitis?
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- Prodrome of URTI with cough and fever
- Expiratory wheeze - Dry cough - Fine crackles - Feeding difficulties, irritability - Tachypnoea and tachycardia - Retractions - Prolongation of the expiratory phase - Hyperinflation |
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What is the main differential of bronchiolitis?
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Asthma
It can be difficult to tell bronchiolitis and asthma apart |
Transient infant wheeze
Pneumonia Foreign body Bronchitis |
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What are 6 signs of respiratory distress?
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- Subcostal, intercostal, sternocostal recession
- Tachypnoea and tachycardia - Nasal flaring - stridor - head bobbing - Grunting |
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What are the signs of upper respiratory tract obstruction?
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- stridor
- suprasternal retraction - croupy cough - hoarse cry |
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What are the signs of lower respiratory tract obstruction?
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- wheeze
- grunting - mucous discharge - rattly cough |
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Describe the pathophysiology of bronchiolitis
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Virus (commonly RSV) incites a complex immune response that results in airway inflammation, oedema, and ultimately airway damage causing obstruction of the lower airways
Decreased ventilation of portions of the lung causes ventilation/perfusion mismatching, resulting in hypoxia |
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What is the management of bronchiolitis?
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Can be managed at home if mild disease
If: poor feeding, lethargy, marked respiratory distress, underlying cardiorespiratory disease, O2 saturation < 90% or age < 6 weeks --> admit, O2, consider IV fluids - Can trial nebulised salbutamol/atrovent (may provide short term relief but not shown to reduce hospital stay) CPAP or ventilation if severe Rarely need to intubate and ventilate |
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When should rebetol be considered in management of bronchiolitis?
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Rebetol (antiviral)
Consider in high risk groups bronchopulmonary disease, CHD, congenital lung disease, immunodeficient |
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Explain the rationale behind the management of bronchiolitis to parents?
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Bronchiolitis is a viral illness and therefore cannot be cured by antibiotics that kill bacteria.
It usually gets better on its own within 10 days Our role is to make sure that during this time the child is breathing and feeding well so if there's a problem with either of these we admit child. |
Bring back to hospital if:
- breathing difficulty - wheeze is getting worse - bluishness around the lips - not feeding well and not producing as many nappies |
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Differential diagnosis of bronchiolitis?
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- Viral triggered asthma or wheeze
- pneumonia - chronic lung disease - foreign body aspiration |
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What are the options for prevention in asthma?
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1st line: Montelukast - singulair
or Inhaled corticosteroid (fluticasone) 2nd line: Increased dose of ICS or combination ICS + montelukast 3rd line: combined ICS + LABA |
Some studies suggest that LABA exposure reduces sensitivity to SABA
NB: never give LABA on their own |
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What is the dosing of salbutamol for asthma?
Spacer and nebuliser |
Single rx hopefully provides 2 hour relief
< 5/20kg years of age - 6 puffs - 2.5mg nebules If > 5/20kg years of age - 12 puffs - 5mg nebules |
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What is the immediate management of asthma?
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O2
Salbutamol (spacer or nebulised) Ipratropium bromide (atrovent) (4th hourly after 2 initial doses) If severe --> oral prednisone or IV hydrocortisone |
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What period does salbutamol need to last before discharge?
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3 hours
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What are the 6 steps in the asthma management plan?
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1. Assess severity
2. Achieve best lung function 3. Maintain best lung function - triggers 4. Maintain best lung function - meds 5. Develop an asthma action plan 6. Educate and review |
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What does the asthma action plan have in it?
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It details:
- regular use of preventer medication - how to increase reliever medication according to signs and symptoms - when and how to access medical care in the event of symptoms worsening |
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What characterises infrequent intermittent asthma?
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- Episodes > 6-8 weeks apart
- Asymptomatic in the interval - Isolated episodes from 1-2 days up to 1-2 weeks - Triggered by an URTI or environmental allergen - Requires treatment only during episodes |
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What characterises persistent asthma?
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Symptoms on most days including:
- sleep disturbance due to wheeze or cough - early morning chest tightness - exercise intolerance - spontaneous wheeze |
Ranges from mild (sx 4-5/7 and readily controlled by low dose preventative therapy) to severe (frequent severe Sx and abnormal lung function requiring intensive therapy)
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What characterises frequent intermittent asthma?
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- Episodes < 6-8 weeks
- Minimal symptoms between episodes - Acute asthma episodes may also occur May benefit from regular preventer (often only in winter) |
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Differential diagnosis for asthma
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- Viral associated wheeze
- Transient infant wheeze - Bronchiolitis (depends on age) - upper airway obstruction - Recurrent viral bronchitis - inhaled foreign body |
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What is the expected peak flow value for mild, moderate and severe asthma?
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Mild: > 60%
Moderate 40-60% Severe: < 40% |
NB: these values are the same for FEV1
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Dosing requirements for ipatroprium bromide in asthma?
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< 20kg
- 4 puffs then q6h, 250mcg q20mins x 3 via nebuliser then q6h > 20kg - 8 puffs then q6h - 500mcg q20mins x 3 via nebuliser then 6qh |
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What questions should you ask to assess asthma control?
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- How often do they use their reliever?
- how often is sleep disturbed due to asthma? - is reliever medication used on waking? - does asthma limit exercise? - how long does the reliever puffer last? - how much school/work has your child missed due to asthma? - ICU admissions? - Has your child ever needed prednisone to treat their asthma? |
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Which variables affect lung function?
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- Gender
- Height (most important variable) - Age |
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At what point do the testes descend into the scrotum utero?
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Testis descend into the scrotum during the 7th month of gestation inside a diverticulum of peritoneum, the processus vaginalis.
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NB: this beings to obliterate shortly before birth and closure is normally completed during the first year of life, levaing only the tunica vaginalis surrounding the testis.
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Which side is it more common to get indirect inguinal hernias?
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Right side
Right testis descends later than the left therefore the processus on the right side is more likely to be patent |
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How do you differentiate a hernia from a hydrocele?
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- Impulse on crying or straining (hernia)
- You cannot get above the swelling (hernia) - Hernia can be reduced, hydrocele canno be reduced - Transilluminable (hydrocele) - |
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What is the treatment for indirect inguinal hernias?
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Surgery - all cases to prevent strangulation
- Herniotomy (ligate and divide the sac) |
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What are the 2 types of indirect inguinal hernias?
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1. Inguionscrotal hernia - hernial sac extends from the internal inguinal ring to the tunica vaginalis
2. Incomplete sac: proximal to an obliterated segment that intervenes between the sac and the tunica vaginalis (more common) |
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Where does obstruction occur with a strangulated inguinal hernia?
How is this different to adults? |
Obstruction occurs at the level of the external inguinal ring
In adults obstruction occurs at the level of the internal inguinal ring |
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What are the features of a strangulated hernia?
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- Tense, tender swelling at the external inguinal ring
- No impulse on crying - May be generalised colicky abdominal pain, vomiting, abdominal distension, constipation (with complete intesintal obstruction - 12 hours after onset) - If delay in Dx - redness and induration over the lump or signs of peritonitis |
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What is the differential diagnosis of a strangulated inguinal hernia?
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Encysted hydrocele of the cord
- Swelling is not tender - Cyst moves readily with traction - Abdominal signs and symptoms are lacking |
Lymphadenitis or a local inguinal abscess
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Complications of a strangulated inguinal hernia?
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Boys:
- testicular atrophy (compression of vessels) Girls: - Ovary can be strangulated inside the sac |
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Treatment of a strangulated hernia?
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Reduce by taxis
If successful - hernitotomy 24 hours later If not successful - surgery |
Taxis
Tips of fingers of one hand apply gentle pressure to the fundus of the hernia while the fingertips of the other hand are cupped at the external ring |
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What is a hydrocele?
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A painless cyst containing peritoneal fluid that has tracked down a narrow but patent processus vaginalis
It is situated around the testis |
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What are the causes of a hydrocele?
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Communication with the peritoneal cavity through a patent processus vaginalis
Less common: secondary to afflication of the tesis or epidiymis (torsion, infection, trauma, tumour) |
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Why can a hydrocele not be emptied by pressure?
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Because of a flap valve at its junction with the processus
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Features of a hydrocele
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- Brightly transculent
- Cannot be emptied by pressure - Upper limit is clearly demonstratable - No impulse on crying or coughing |
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Management of hydrocele?
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- unilateral or bilateral hydroceles are common in first few months - will often absorb spontaneously
Treat if they persist > 2 years > 2 years - surgery herniotomy to release the fluid |
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By what age should the testes have descended into the scrotum?
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3 months of age
(Dr Holland says wait until 6m) |
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What acts on the testis to make them descend?
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Abdominal pressure
Gubernaculum Testosterone Mullerian inhibiting substance |
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Complications of undescended testis?
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- Infertility (high temperature)
- Higher risk of seminoma (cancer) - not altered by surgery - more vulnerable to trauma |
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Management of undescended testis?
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After 6 months
Orchidopexy (surgery to bring testis down into scrotum) |
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What happens in torsion of the testis?
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The spermatic cord undergoes torsion, obstructing the spermatic vessels
It is caused by inadequate fixation of the testis within the scrotum resulting from a redundant tunica vaginalis, allowing excessive mobility of the testis (bell clapper deformity) |
NB: surgical emergency
high incidence of necrosis of the testis |
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What are the clinical signs of testicular torsion?
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- Sudden onset
- Pain in the testis and/or ipsilateral iliac fossa - nausea, vomiting - Swollen testis and epididymis, tender - Often axis of testicle has changed - Palpable thickened cord - Scrotal oedema |
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Treatment of testicular torsion
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Urgent exploration of the scrotum to untwist the testis and epididymis and to anchor both it and the contralateral testis to prevent subsequent torsion
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Don't do an ultrasound - WASTE OF TIME
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What is a testicular appendage?
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Hydatid of Morgagni is the commonest (remnant of the cranial mullerian duct)
There may be other appendages left on the spermatic cord and epidiymis |
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Clinical signs of torsion of an appendage
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- Severe pain in scrotum
- Blue black spot may be seen through the skin near the upper pole of the testis - palpation causes extreme pain - palpation of the testis itself causes minimal discomfort |
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Treatment of torsion of an appendage
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Exploration is mandatory if cannot tell whether torsion of testis or appendage
Can remove the tender pea of a twisted appendage which provides immediate relief of symptoms and prevents recurrence |
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What is a varicocele?
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Enlargement of the veins of the pampiniform plexus in the spermatic cord
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Usually left sided
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At what age does a varicocele usually occur?
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Boys over 12 years of age, at or before the onset of puberty
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Clinical features of a varicocele
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- Mass of veins best seen and felt when patient is standing
- Feels like a bag of worms - Varicosities will emtpy when the boy lies down |
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Complications of a varicocele
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Infertility
Absence of pampiniform plexus which is responsible for lowering the temperature of the testis by cooling the arterial blood flow to the testis |
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Treatment of varicocele
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High ligation of the spermatic vessels or ligation of the cremasteric veins which anastomse freely with the spermatic veins should prevent recurrence
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What is this?
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Impetigo
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What is this?
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Chickenpox
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What is this?
Which arteries and nerves are potentially affected? |
Open supracondylar fracture of right humerus with division of brachial artery
Potentially affected: - brachial artery - median, radial, ulnar nerve |
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What is this?
Which rule is applied to this x-ray? Treatment |
Monteggia fracture dislocation
Ulnarly angulated Rule: if one bone is broken the other one is either broken or dislocated Treatment: Closed reduction and cast immobilisation |
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What is this?
Treatment |
Salter-Harris 2 fracture of the distal radial epiphysis
Treatment: closed reduction |
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What is the satler harris classification of fractures?
I-V |
I - separation through the physis (growth plate)
II - Fracture through a portion of the physis but extending through the metaphysis III - Fracture through a portion of the physis extending through the epiphysis and into the joint IV - fracture across the metaphysis, physis and epiphysis V - crush injury to the physis |
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What is important about ligaments in children?
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Ligaments are stronger than the growth plate.
It is easy to produce epiphyseal separation Difficult to produce dislocations or sprains |
Young bones are also more porous
- tolerate more deformation (plasticity) - fails in compression as well as tension |
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When would you expect bone remodelling to occur?
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- > 2 years growth remaining
- Fracture is near the metaphysis - Deformity is in the plane of joint movement |
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When is remodelling not expected to occur?
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- Intra-articular fractures
- diaphyseal fractures with gross angulation, shortening or rotation - fractures with deformity at right angles to the plane of joint movement |
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Which bone does overgrowth usually occur in?
What is the physiology behind overgrowth? |
Femur
1-2 cm overgrowth after fracture |
- Fracture stimulates longitudinal growth
- increased blood flow associated with fracture healing stimulates growth plate - Loss of "tether" of periosteum |
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What is an epiphyseal injury?
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Avulsion at site of ligamentous attachment
Osteochondral fracture Compression fracture |
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Dose of morphine required for analgesia in children?
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0.1-0.2mg/kg
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What is happening here?
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Psudosubluxation
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What is happening here?
How will the child present? Treatment |
Pulled elbow - separation of unossified epiphyses
Child will present with a refusal to use arm and elbow in extension and the forearm in pronation Distressed only on elbow movement |
Treatment
Supination of flexed elbow If unsuccessful reconsider diagnosis or rest in C & C (will usually get better by itself) |
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What is happening here?
Treatment |
Elbow dislocation associated with medial epicondylar avulsion
Treatment by closed reduction |
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What's happening here?
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Lateral condyle fracture
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What's happening here?
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Tillaux fracture
External rotation injury Ligament has pulled a small bit of bone off the tibia |
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What is intussusception?
How would you explain it to parents? |
Invagination of a proximal segment of bowel into the distal bowel lumen
Commonest occurrence is a segment of ileum moving into the colon through the ileo-caecal valve |
Sliding of one portion of bowel into the other portion - like a telescope
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Commonest age group for intussusception?
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Can occur at any age but commonly occurs
2 months - 2 years Peak incidence 5-9 months |
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Fetaures in the history of intussception
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Intermittent pain
Colicky pain, severe, may be associated with child drawing up his legs Tyipcally occurs 2-3 time per hour During episodes of crying child may look pale Pallor and lethargy may be the predominant presenting signs Vomiting (bile stained vomiting is a late sign) Bowel motions - blood and/or mucus, classic red currant jelly stools (late sign) Diarrhoea May be a preceding respiratory or diarrhoeal illness |
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What are you looking for when examining a child with suspected intussuception?
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Pallor, lethargy
Abdominal mass - sausage shaped mass RUQ or crossing midline in epigastrium or behind umbilicus Distended abdomen Stool - blood stool/occult blood +ve Signs of acute bowel obstruction Hypovolaemic shock (late sign) |
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Management of a child with intussception
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- IV fluids if signs of shock
- Abdominal x-ray - exclude perforation or bowel obstruction If suggests small bowel obstruction do US - If suggestive give IV cefazolin/metronidazole - Air enema - diagnostic and therapeutic |
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Risk factors for intussception
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CF
Post abdominal operation Can complicate mucosal haemorrahge - HSP, otitis media, gastroenteritis, URTI |
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What signs of intussuecption do you see on a plain x-ray?
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May be normal or show non specific abnormalities
Small bowel obstruction with air-fluid levels in dilated small bowel Target sign - 2 concentric circular radiolucent lines usually in the right upper quadrant Cresent sign - a crescent shaped lucency usually in the left upper quadrant with a soft tissue mass (only see with barium) |
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Classic triad in intussusception?
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Colicky abdo pain - knees pulled up to chest
Red currant jelly stools palpable sausage shaped mass |
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What is this sign?
What does it suggest? |
Crescent sign
Intussuception |
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What does this show?
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Target sign
Intussusception |
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What does this show?
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Longitudinal scan of the intussuception showing the sandwiched layers
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Differential diagnosis of intussuception
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Gastroenteritis
(Intussusception differentiated by small volume and limited duration of stools) Wind colic (common in first 3 months) Strangulated inguinal hernia |
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What are the complications involved in an air enema?
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Small risk of bowel perforation and bacteraemia
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Contraindications for air enema?
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Do not perform reduction in patients with prolonged intussusceptions with signs of shock, peritoneal irritation, septicaemia - this indicates necrotic bowel and requires surgical removal
Intestinal perforation i.e. free air on xray indicates perforation |
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Prognosis of intussuception
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Untreated - fatal
- Most will recover if reduced within 24 hours - > 24 hours - mortality rates rise rapidly - Recurrence rate after reduction is 10%, surgical reduction is 2-5% |
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Symptoms of malrotation with volvulus
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- Recurrent vomiting (bilious intermittently)
- FTT with vomiting - Sudden onset of abdominal pain and then shock |
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At what age does malrotation with volvulus usually present
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Generally within 2 months of life
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Treatment of malrotation with volvulus
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Urgen laporotomy to untwist the bowel and to perform a Ladd procedure to broaden the messentery of the small bowel to prevent subsequent volvulus
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What is volvulus?
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Small bowel twists around the superior mesenteric artery resulting in vascular compromise to large portions of the midgut
--> ischaemia and necrosis of the bowel |
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Differential diagnosis of intestinal malrotation
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Young infants: necrotising enterocolitis, viral gastroenteritis, meckel's diverticulum, sepsis
Older infants: intussuception, appendicitis, |
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What investigations should be done in a child with suspected malrotation?
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- Plain xray - gasless abdomen and double bubble sign
- Upper GI contrast series - to visualise the duodenum - Barium enema and ultrasonography can be useful adjunts when abnormal findings are present |
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Explain malrotation with volvulus to a parent
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In utero - intestines begin straight and then move and rotate to the location that we are born with.
Your child has not had the correct rotation of the intestines so her bowel is predisposed to becoming twisted. This can stop poo going through but can also twist around blood vessels stopping adequate blood supply to other parts of her intestine |
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Explain the surgical treatment of malrotation with vovulus to a parent
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Midline scar, untwist the intestines, place bowel in correct location and then fix up where the bowel attaches to each other so that it won't happen again.
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Complications of the surgery for volvulus
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Short gut syndrome - if necrotic bowel is present at the time of surgery
Small bowel obstruction from adhesions Infection Bleeding Perforation |
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Which infectious agents are newborns most susceptible to?
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Staph
E Coli Group B strep herpes Listeria Gram negatives Chlamydia |
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What is this?
What does it signify? |
Double bubble sign
Malrotation with volvulus |
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What is this?
What does it signify? |
Double bubble sign
Malrotation with volvulus |
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What is a meckel diverticulum?
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Remnant of the embryonic yolk sac which is also referred to as the vitelline duct.
The vitelline duct connects the yolk sac to the gut in a developing embryo and provides nutrition unti lthe placenta is established. Meckel's diverticulum is a result of partial or complete failure of involution of the duct |
2% of people have them
2 inches from the ileum 2 inches long |
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When do symptoms of a meckel's diverticulum usually arise?
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0-2 years
Can occur within 1st decade |
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Symptoms of meckel's diverticulum
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Rectal bleeding (due to secretion of acid)
Stool brick coloured or currant jelly coloured Bleeding Partial or complete bowel obstruction (most commonly diverticulum acts as a lead point of an intussuception) |
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Symptoms of meckel's diverticulitis
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Similar to appendicitis
Central abdominal pain that progresses to the right lower quadrant Vomiting, fever etc |
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Diagnosis of meckel's diverticulum
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Meckel radionuclide scan
(mucus secreting cells of the ectopic gastic mucosa take up the technetium-99m permitting visulatisation of the diverticulum) |
NB: radiographs no value, barium studies rarely fill the diverticulum
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Treatment of meckel's diverticulum
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If symptomatic - surgically remove
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Symptoms of appendicitis
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Periumbilical pain - moving to RIF
N and V Anorexia Low grade fever Peritonism Psoas sign - pain on hip extension Obturator sign - pain on hip internal rotation |
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Investigations in appendicitis
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CT - gold standard
Ultrasound |
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Treatment of appendicits
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Fluids and correction of electrolyte deficits
Surgical removal of the appendix Irrigation of the peritoneal cavity to remove pus and contaminated free peritoneal fluid Effective antibiotic treatment to cover aerobic and anaerobic organisms commencing before surgery |
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Differential of appendicitis
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Meckel's diverticulum
Mesenteric adenitis Simple colic Gastroenteritis |
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If a child has reduced urine output, thirst but no clinical signs what level of dehydration do they have?
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<3%
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If a child has reduced urine output, thirst, dry mucous membranes, mild tachycardia, delayed capillary refill time > 2 secs, tachypnoea what level of dehydration do they have?
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5%
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What is the difference in signs between 5% dehydration and 7-9% dehydration?
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7-9% has:
Reduced skin turgor Sunken fontanelles Sunken eyes Mottle skin CRT > 3 secs |
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What is the difference between 10% dehydration and 7-9%?
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10% has:
weak, rapid breathing poor perfusion hypotension shock |
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Is pyloric stenosis present at birth or does it develop after birth?
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Develops after birth
Symptoms usually around 2-4 weeks after birth Rare in infants < 10 days or > 11 weeks |
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Symptoms of pyloric stenosis
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3 ps
Palpable mass - olive sign at right rectus abdominus mm Peristalsis visible - LUQ to epigastrium Projectile vomiting (non-bilious) - occurs after feeding - baby intially wants to refeed Hypochloremic metabolic alkalosis |
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When do these present?
Pyloric stenosis Malrotation with volvulus Intussuception |
Pyloric stenosis: 2-4 weeks
Malrotation with volvulus: first 2 months Intussception: 3-18 months |
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Investigations in suspected pyloric stenosis?
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EUC - extent of electrolyte acid base imbalance
Venous blood gas Ultrasound |
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Treatment of pyloric stenosis
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Correction of the fluid electrolyte abnormality
Pyloromyotomy (surgery) |
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Differentials for pyloric stenosis
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Adrenal insufficiency
UTI Malrotation with volvulus GORD Obstructed hernia Intussusception Duodenal web |
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Differential diagnoses of testicular torsion
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Torsion of the testicle
Torsion of the appendage Incarcerated or strangulated hernia Epididymo-orchitis |
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Prior to operation what needs to be done?
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Conset
Fluids Group and hold Nill by mouth |
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3 things to look at when tanner staging a male?
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External genitalia - scrotum, testes, penis size
Pubic hair |
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2 things to look at when tanner staging a female?
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Breast development
Pubic hair |
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What are the tanner stages for external genitalia in boys?
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What are the tanner stages?
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What investigations need to be done if a UTI is suspected?
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Urine Analysis:
Nitrites + leucocytes If one positive possibly a UTI - 2 positive definitely a UTI Then urine microscopy and culture WBC>100 x 10'9 Single organism > 10'7 (catheter) or 10'8 (voided) |
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What % of 5 and 10 year olds wet the bed?
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10% of 5 year olds
5% of 10 year olds |
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Causes of hypertension in children?
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REDCAT
R: Renal parenchymal disease (80% of cases prior to adeolsence), Renovascular E: Essential D: Drugs C: Coarctation of the aorta A: Adrenogenital syndrome, hyperaldosteronism T: Tumours |
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When is a child considered hypertensive?
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When 3 recordings give levels above the 95th centile for age
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In a kid with hypertension what questions do you want to ask on history?
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UTI
Neonatal umbilical catheterisation Family history: HTN or stroke Drugs |
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What are you looking for on examination of a child with hypertension?
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Neurocutanous pigmentation
Renal artery bruits Delayed femoral pulses (coarctation of the aorta) Palpable renal masses (tumour) |
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What investigations should be done in a child with hypertension?
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Obese, adolescent, mild HT and FH
Check metabolic parameters Consider sleep study If not obese of adolescent EUC, CMP, urinalysis, doppler U/S, ECHO, ophthalmologist, genetics If abnormal - further tests: DMSA, MRA, angiography If normal - plasma renin and aldosterone, urine catelcholamins, TFT |
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Describe the appearance of a maculopapular rash
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Pink/red flat and raised spots that may be of different sizes, confluent or single
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Differential diganosis of a maculopapular rash
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Measles
Rubella Scarlet Fever Kawasaki disease Erythema infectiosum (fifth disease) Roseola Infantum |
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Differential diagnosis of a vesciular rash
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Chicken pox (varicella zoster)
Shingles Hand foot and mouth Herpes simplex Impetigo Molluscum contagiosum |
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Important points in a history of a rash
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When did it start? onset/distribution/timing
Other symptoms - fever, URTI, itch Vaccination status Known allergies Any obvious trigger for the rash? foods, contact with plants Prior infectious diseases and/or rashes |
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Describe the MMR vaccine
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Live attenuated vaccine
Contains mixture of 3 viruses - measles, mumps, rubella Induce production of both effective antibody and cell mediated immunity Given at 12 months and 4 years >90% have full immunisation after first dose |
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What is this picture?
What are some of the complications of this? |
Measles
Complications: Bronchopneumonia and croup Encephalitis Subacute sclerosing panencephalitis Secondary bacterial infection: otitis media, sinusitis |
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Describe the rash seen in measles
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Koplik (small white papules on a red base on the buccal mucosa) followed by a rash 1-4 days later
Maculopapular rash: red/pink flat and rasied spots of varying sizes Start behind ears and face and spread downwards |
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Briefly describe the epidemiology of measles in Australia
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Airborne spread - very contagious
Herd immunity of 90% shown to produce disease free zones Outbreaks every 2 years in non-immunised populations No deaths due to measles since 95 (introduction of 2nd vaccine) |
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Public health implications of measles
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Notify Department Of Health (manditory notification in Australia)
Identify non-immunised contacts at daycare and home Catch up immunisation for child - MMR now and 5 years later |
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Apart from rash what other features do you see with measles?
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Highly febrile
Child looks unwell Acute catarrhal illness - coryza, cough, conjunctivitis |
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Treatment for measles?
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Supportive
Can give prophylactic immunoglobulin to prevent disease if given within 6 days of exposure NB: incubation is 10-14 days Vit A supplementation in some children (given in developing countries) NB: antiviral therapy not effective in otherwise normal patients |
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Which virus causes:
- measles - rubella ? |
Measles: morbillivirus
Rubella: Rubivirus |
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What is Kawasaki disease?
When does it peak? |
Acute vasculitis of childhood of unknown aetiology
Peaks 6-18 months |
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What are the clinical manifestations of Kawasaki disease?
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Fever + 4/5 of:
- bilateral conjunctival infection - maculopapular rash (feet, knees, axillary and inguinal creases) - oral changes: red mouth/pharynx/tongue and cracked lips - swelling of hands and feet - later desquamation - lymph nodes |
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Complications of Kawasaki disease
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Myocarditis
Coronary artery aneurysms Thrombi |
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Treatment of Kawasaki disease
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High dose aspirin
IVIG |
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Prognosis of Kawasaki disease
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Recovery is complete for those who do not develop coronary artery disease
Recurrent illness occurs in about 1-3% of cases |
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Symptoms of congenital rubella syndrome
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Eye, cardiac, CNS abnormalities
Cataracts, retinopathy, glaucoma Congenital heart disease Microcephaly, encephalitis |
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If mum gets rubella what time is the highest risk to baby?
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1st 4 months
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Difference between rubella and measles symptoms?
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Measles: prodroma - coryzal symptoms
Rubella: rash is first indication, can get lymphadenopathy - not many other symptoms |
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What causes scarlet fever?
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Group B streptococcus
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Symptoms of scarlet fever
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Strawberry tongue
Sandpaper rash Sore throat Peri-oral sparing non-pruritic non-painful peeling |
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Contraindications to giving the MMR vaccine?
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Immunosuppression
Past history of anaphylaxis to neomycin or gelatin (egg allergy no longer contraindicated) Anaphylaxis to MMR vaccine |
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Differential diagnosis of a purpuric rash
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Meningitis
Henoch Scholein Purpura ITP |
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Differential diagnosis for this rash?
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Meningoccocus
ITP HSP |
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Differential diagnosis of this rash?
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Varicella zoster
HSV Molluscum contagiosum Hand foot and mouth? |
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Complications of varizella zoster
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Secondary bacterial infection with group A strep and staph aureus
Less common in children pneumonitis, cerebellitis, hepatitis, arthritis |
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Difference in distribution between small pox and chickenpox
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Small pox: limbs and face
Chicken pox: trunk and face |
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Describe the chicken pox vaccine
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Live attenuated varizella zoster virus wild type strain
> 95% of children between 12 months and 12 years will develop immunity after a single dose 95% effective at preventing severe varicella It is less effective at prevening the milder forms Given at 18 months and then 10-14 years (booster) but recommended for all children between 18 months and 14 Immune response is less in adults and adolescents so need 2 doses administered 4 weeks apart very important to give to non-immune women before pregnancy |
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What is this?
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Singles
Herpes zoster clustered between 1 sometimes 2 dermatomal distributions |
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Risk factors for herpes zoster
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Children who get varicella in first year of life
Children whose mum gets varicella in 3rd trimester of pregnancy |
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What are the 3 outcomes if a mum gets chickenpox during pregnancy?
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1. Congenital varicella
Eye defects, limb abnormalities, poor sphincter control, prematurity, early death 2. zoster in normal child 3. Neonatal chickenpox (occurs 48 hours - 5 days after delivery) - no time for mum to pass on antibodies - give IVIG |
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Why do you not give aspirin to a child with chickenpox?
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High risk of getting Reye syndrome
Acute hepatic encephalopathy and fatty infiltration of liver - 50% mortality |
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Which vaccines are live?
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MMR
Varicella Oral polio |
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Which vaccines are toxoid?
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Diptheria
Tetanus |
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Which vaccines are inactivated?
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Influenza
Inactivated polio |
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Which vaccines are component?
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Hib
Hep B, Hep A Pneumococcal Meningococcal |
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Describe the abnormalities in this picture
Name 2 likely causative organisms |
Vesicular papules
Skin vesicles surrounded by an erythematous base and shallow ulcers HSV Hand foot and mouth disease (coxsackie virus) |
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How do you diagnose HSV?
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Newborns - culture
Older children - swab of vesicle - PCR |
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How do you distinguish between HSV and enterovirus?
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HSV: gums, more anterior
Enterovirus: gums not involved, posterior, more acute |
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Contradinciations to the chickenpox vaccine
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Allergy
Impaired immunity Women should not fall pregnant up to 4 weeks after the vaccine |
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When do you give immunoglobulin therapy for chickenpox?
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Neonate under 28 days of age
immunocompromised complicated chickenpox Newborns whose mother's have had chickenpox 48 hours before or 5 days after delivery Hospitalised premature infants under 28 weeks or 1 kg regardless of history Hospitalised premature infants with no previous history of varicella |
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Treatment of herpes zoster
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In normal children do not need to treat
In immunocompromised must give acyclovir |
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What is the difference between herpes zoster in an immunocompromised child versus a healthy child?
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Immunocompromised child it will be disseminated spreading to the lungs, liver, brain and other organs
Often rash might not occur in immunocompromised it may just go straight to the organs |
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What is herpetic whitlow?
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HSV infection of the paronychia but generally applied to HSV infection of the fingers and toes
Associated with gingostomatitis |
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Features of neonatal HSV infection
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Skin, eye, mouth lesions
Encephalitis Disseminated infection involving multiple organs Pneumonitis |
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Which organisms commonly colonise impetigo?
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Staph aureus
Group A beta haemolytic strep |
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What is this?
What is the treatment for it? |
Impetigo
Most cases resolve spontaneously within 2 weeks Topical chlorhexadine Antibiotics |
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Treatment of scarlet fever
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Course (10 days minimum) of antibiotics to prevent GAS sequalae
amoxicillin or penicillin |
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What is this?
What is it caused by? |
Scarlet fever
Group A strep |
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What is erythema infectiosum caused by?
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Parvovirus B19
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Symptoms of erythema infectiosum
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Prodromal period: low grade fever, URTI, headache
Rash 2 stages: 1. Slapped cheek 2. 1-2 weeks later lacy Maculopapular rash on arms and legs |
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Complications of erythema infectiosum
(parvovirus B19) (Fifth disease) |
Joint aches
Thrombocytopenic purpura Rarely aseptic meningitis Risk to pregnant women (hydrops fetalis) and to haematological malignancy |
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Which virus is roseola infantum caused by?
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Human herpes 6 and 7
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Clinical features of roseola infantum
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Fever falls with onset of discrete rose coloured rash
Maculopapular rash - child looks well cf. measles child looks unwell Febrile seizures |
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Treatment of roseola infantum
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Acyclovir only in immunocompromised
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Which antibiotic is community acquired MRSA highly resistant to?
What should be used instead |
Erythromycin
Use vancomycin |
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Over what period is chickenpox infectious?
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48 hours prior to onset of rash
Until lesions crust over (Usually 3-7 days) |
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Over what period is measles infectious?
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4 days pre rash - 4-6 days post rash
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Over what period is rubella infectious?
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7 days pre rash to 5 days post rash
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Which rash occurs exclusively during infancy?
What months? |
Roseola infantum
6 months - 15 months |
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14 year old girl with worsening headaches. What further history do you want to know?
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How long have they been going and how long do they last for?
Any triggers? Does anything make them worse or better? Has she had headaches like this in the past Nausea or vomiting Photophobia/ Phonophobia Visual signs or double vision Where is the pain? What time of day does she get them? |
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What are the signs of raised ICP on a clinical exam
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Papilloedema
Focal neurological signs Vomiting Hypertension, bradycardia, irregular respiration (Cushing's triad) Lethargy or decreased consciousness Ataxia 6th and 3rd nerve palsy |
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Explain the pathophysiology of 2 non-localising signs of raised ICP
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6th nerve palsy: raised pressure, 6th nerve longest pathway in the brain - pushed against the petrous bone
Papilloedema - the optic nerve is a continuation of the CNS, raised pressure transfers along it, stops axoplasmic flow and causes swelling of the optic head Decreased consciousness - pressure can push the brainstem down, pushing the cerebellar tonsils into the foramen magnum --> putting pressure on the brainstem affecting respiration and consciousness centres |
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When is a CT scan indicated in a patient with a headache?
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Focal neurological signs
Raised BP Papilloedema Decreased level of consciousness |
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Complications of raised ICP
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CN palsies
Seizures Herniation Consciousness Permanent neurological signs Death |
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What does HEADSS stand for?
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Home
Education, eating, exercise Activity Drugs Suicide Sex |
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How would you explain confidentiality to a patient
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I won't tell anyone else what we talk about except in 2 circumstances
- If i think you are going to harm yourself or others or are in danger If this was to happen I would discuss with you first who I was going to tell and why |
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Give 3 reasons when confidentiality needs to be broken
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If you are going to harm yourself or others or are in danger of being harmed by others
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What features on history might make you think of raised ICP
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Worse in the morning
Vomiting Worse on coughing/sneezing/bending Progressively worsening Personality or behavioural changes Focal neurological symptoms |
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Acute causes of headaches
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Sinusitis, dental caries, otitis media
Systemic general illness with fever Meningitis Trauma Subarachnoid haemorrhage |
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Chronic causes of headaches
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Migraine
Tension Raised ICP Behavioural/stress |
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Treatment of migraine
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Avoid opiates
Initially paracetamol (20mg/kg stat then 15mg/kg 4 hourly) or NSAIDs (2.5-10mg/kg/dose 6-8 hourly) |
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What other agencies could be involved in psychosocial causes of a headache
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Psychologist
School counseller Local mental health team GP |
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Differential diagnosis of abdo pain in a teenage girl who has a history of IDDM, depression, truanting, alcohol
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Hypoglycaemia
Diabetic ketoacidosis Period pain Ectopic pregnancy Metabolic disturbances Gastroenteritis |
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3 bedside investigations that should be done in a teenage girl who has abdo pain and a history if IDDM, depression, alcohol
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Blood glucose
Urine dipstick Pregnancy test |
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How do you manage DKA?
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Airway/breathing
Fluid requirements - isotonic NS Insulin K+ - if low |
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What single test can be done to assess long term compliance in a child with IDDM?
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HBA1c
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Symptoms of DKA
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Polyuria
Thirst Blurred vision Abdominal pain Vomiting and nausea Leg cramps |
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Signs of DKA
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Dehydration
Hypotension Cold extremities Acetone on breath Tachycardia Kussmaul's breathing Hypothermia Confusion, drowsiness |
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Investigations in suspected DKA
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Venous blood
FBC, EUIC, Blood gas Blood ketones Check for precipitating cause GAD, anti-islet, anti-insulin antibodies if newly diagnosed IDDM |
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Explain the mechanism for ketonuria in DKA
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High glucose and not enough insulin or increased resistance to insulin (can occur when sick) - cannot utilise glucose
Fat cell TAGs broken down for energy Fatty acids taken up by liver mitochondria and oxidised (insulin usually blocks this by inducing manolyl CoA which inhibits enzyme Cat 1 which promotes uptake) Gluconeogenesis is activated and uses up the substrate for the citric acid cycle so it fails Acetyl CoA is converted to ketone bodies (acetoacetate, beta hydroxybutyrate, acetone) Ketones used as brain food Ketones are acidotic + protons are generated from the TAG breakdown |
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3 factors that may cause non-compliance in an adolescent
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Peer pressure
Embarrassment Inability to understand that actions now affect things later |
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Causes of Cushing's syndrome
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Exogenous steroid excess
Pituitary adenoma Adrenal tumour Ectopic ACTH secretion Congenital adrenal hyperplasia |
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Features of cushing's syndrome
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Buffalo hump
Moon face Central adiposity Striae Thin skin Easily bruised Proximal myopathy |
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Name some lifestyle risk factors for obesity in adolescents
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No spontaneous activity
Don't eat breakfast Sleeping patterns mean there is less daylight in which to exercise More studying which is sedentary Greater than 2 hours TV time a day Eating high calorie foods |
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Possible organic causes for obesity
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Hypothyroidism
Cushing's syndrome Prader Willi syndrome |
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What strategies on public health policy help to combat obesity
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Ad campaigns
Healthy eating programs in schools Safe areas for exercise Bike lanes Better public transport |
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List 3 adult diseases and how adolescent obesity contributes to these
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Diabetes type 2
Cardiovascular disease Arthritis Obstructive sleep apnoea |
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What tests should be ordered to find out if someone has significant obesity
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24 hour urinary free cortisol
TFTs ACTH levels CT of pituitary/adrenals Ultrasound kidneys Blood glucose - oral glucose tolerance test |
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What things on history would suggest an eating disorder?
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Abnormal thoughts about her body weight and body image
Decreased levels of food Vomiting after meals Binge eating and then purging Excessive exercise Recent weight loss Use of diet pills, laxatives, diuretics Amenorrhea |
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What would you look for on examination of a child with a suspected eating disorder?
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Wt, Ht, Head circumference
Mm wasting Excess skin folds BP, HR Fine or corsity of hair Tanner staging |
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Which BMI suggests an eating disorder
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< 17.5
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What investigations would you order in a child with a suspected eating disorder and why?
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FBC - evidence of anaemia and low WBC
EUC - dehydration, diuretic use, water excess TFT - no organic cause for loss of weight ECG - to assess bradycardia or evidence of effects of electrolyte abnomalities |
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What are the long term sequalae of an eating disorder
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Osteoporosis
Amenorrhea and infertility Depression Bradycardia and arrhythmias Death |
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Explain the mechanism behind
increased urea Decreased K Increased Cl In someone with an eating disorder |
Increased urea - increased reabsorption of urea occurs in dehydration
Metabolic alkalosis occurs with vomiting and purging --> increased K secretion Aldosterone (dehydration) --> increased K secretion Dehydration/aldosterone --> more enac, more negative lumen, more Cl leaves the cortical collecting duct into the body --> high serum chloride |
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What is esotropia?
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A form of strabismus "squint" where one or both eyes turns inwards
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What is exotropia?
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A form of strabismus "squint" where one or both eyes turns outwards
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What is hypertropia?
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A form of strabismus where the visual access of one eye is higher than the fellow eye
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What is hypotropia?
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A form of strabismus where the visual access of one eye is lower than the fellow eye
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What is this?
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Epiphora (excessive tear production)
Mucocele of the lacrimal sac due to (mucous cyst) congenital nasolacrimal duct obstruction Occurs in 10% of babies |
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What are some causes of epiphora?
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Epiphora (excessive tear production)
- Mucocele of the nasolacrimal duct - Glaucoma - Epiblepharon (corneal irritation from the lashes) - |
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How do you manage epiphora due to nasolacrimal duct obstruction?
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Exclude other causes
Bathe with saline Massage over lacrimal sac Topical antibiotics ? Probe and irrigate if not resolved by 1 year |
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What is this?
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Congenital glaucoma
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What is this?
What are some clinical features here? |
Neonatal conjunctivitis
Swollen red eye lids Mucopurulent discharge Conjunctiva injected |
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What's happening here?
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Neonatal conjunctivitis
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How do you manage neonatal conjunctivitis?
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Conjunctival swab
Topical antibiotics Systemic antibiotics |
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What possible organisms could be involved in neonatal conjunctivitis?
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Bacterial - gonococcal (onset day 1); other incl staph (onset day 4-5)
Viral Chlamydia (onset day 10) |
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What's happening here?
What features can you see? |
Bacterial conjunctivitis
Eyes injected and mucopurulent discharge |
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How do you manage bacterial conjunctivitis?
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Conjunctival swab - not usually indicated
Topical antibiotics If no treatment will clear in 15 days but usually treat so they can go back to childcare sooner Very contagious - wash hands, stay home from school, use separate towels and wash them |
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What is this?
Describe the features? |
Herpes simplex blepharo-conjunctivitis
Vesicles involving right upper and lower eyelids Watery right eye |
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Management of herpes simplex blepharo conjunctivitis?
|
Topical acyclovir
Systemic acyclovir - if primary infection - minimises recurrences |
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Describe this eye
What is happening here? How is this managed? |
Watery eye
Eye injected Eye looks ulcerated Herpes simplex keratitis Child will have photophobia Use fluorescein instilled into conjunctival sac to assess it Manage with topical acyclovir ointment DO NOT USE steroid eye drops - can get corneal scarring |
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What is amblyopia?
|
= lazy eye
Vision doesn't develop in the eye due to a barrier in visual development |
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|
Common causes of amblyopia
|
Strabismus (most common) - adaptive to avoid diplopia
Refractive - poor quality image on retina - poor quality transmited to cortex - doesn't stimulate normal cortical development Other Unilateral cataract Ptosis |
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Management of ambylopia
|
Provided it is detected early, while the developing visual cortex is immature it is treatable
Mx: correcting refractive errors Patch forcing the child to use the ambylopic eye |
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How would you describe this?
|
Esotropia
Eyes deviated inwards |
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What is hyperopia?
|
Far sightedness
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What is myopia?
|
Short signtedness
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What should you immediatley think of with sudden onset strabismums associated with diplopia?
|
Intracranial pathology
Raised intracranial pressure |
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|
What's happening here?
What are some differentials |
Leukocoria
DDx Retinoblastoma (eye filled with tumour) Cataract |
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What are some presenting signs of retinoblastoma?
|
Leukocoria
Strabismus Secondary glaucoma Uveitis |
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Describe this picture
What is happening? |
Redness or right eye
Swelling and redness of right eyelids Preseptal cellulitis |
Child is non febrile and has recently had an URTI
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Management of preseptal cellulitis
|
If infection tracks backwards can get infection in cavernous sinus
Admit to hospital IV antibiotics Imaging if no better in 48 hours |
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|
Descibe this picture
What is happening here? |
Redness and swelling of left eyelids
Left proptosis |
Child will be febrile and unwell
|
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How is orbital cellulitis managed?
|
Orbital cellulitis is a medical emergency
Admit to hospital IV antibiotics CT scan head and orbits Drain abscess if present |
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What is going on here?
|
Erythematous lump on lower eyelid
Chronic inflammation of a meibomian gland = sterile chemical inflammation rather than infection Occurs due to blockage of the opening of the gland at the lid margin |
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Management of meibohmian cysts
|
Warm compress may help drainage
Systmic/topical antibiotics incise and currette under GA if particularly large or persistently inflamed |
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What must you think about in a child with retinal haemorrhages?
|
Non accidental injury
|
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|
Describe this picture?
What should we be worried about Management |
Ptosis of right upper eyelid
Possibility of decreased vision in right eye Management: Monitor visual acuity Refraction Surgery - functional (if interfering with visual development) = early: cosmetic - 4-5 years |
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In a child with suspected croup, what do you want to know on the history?
|
When did it start?
Fever? What type of cough? Vomiting Still eating Coyzal symptoms Are symptoms worse at night? Wheeze Vaccinations Could they have possibly swallowed anything? |
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What are you looking for on examination of a child with suspected croup?
|
Hoarseness
Stridor Barking cough Signs of respiratory distress Crackles, wheeze, effusions Airway obstruction |
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Differential diagnosis for a child with suspected croup?
|
Upper airway obstruction - peak time for this is 18 motnhs
Epiglottitis Acute bronchitis or bronchiolitis Asthma - likely to be expiratory noises |
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Would you perform a CXR on a child with suspected croup?
|
Most investigations are not useful in ruling in a diagnosis - croup is a clinical diagnosis
CXR: no - croup is a clinical diagnosis but if complicated (i.e. with wheeze and crackles) may be beneficial to figure out if there is a concomittant infection |
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Would you perform a lateral airways x-ray on a child with croup?
|
No
You don't need to, croup is a clinical diagnosis In severe upper airway obstruction, the patient may become agitated and worsen the obstruction |
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Would you perform oximetry on a child with croup?
|
Yes - it can be useful in detecting deterioration
BUT O2 saturation can be near normal in severe croup and low in mild croup so not entirely accurate |
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Would you do an ABGs on a child with croup?
|
No this is invasive and is unlikely to change management
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Would you do NPA and culture on a child with croup?
|
Only if unsure of the diagnosis or suspicious of the bacterial or viral cause
|
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|
Which organism is most likely involved in croup?
|
Parainfluenza virus type 3 is the most common
RSV |
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What are the criteria for the decision to admit a child with croup?
|
Ongoing stridor at rest
Children with pre-existing narrowing (e.g., subglottic stenosis) or with Down's syndrome Parent's compliance and ability for early review Respiratory distress |
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Initial management of croup following low dose O2 if child has dusky appearance?
|
Give high dose O2
Signs of hypoxia or severe obstruction --> nebulised adrenaline (shrinks mucosa and decreases vascular permeability) and dexamethasone (reduces airway oedema - can be reactive swelling to adrenaline) If no signs of hypoxia or severe obstruction --> oral steroid |
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How does nebulised adrenaline help in croup?
|
Reduces bronchial and tracheal epithelial vascular permeability thereby reducing airway oedema
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|
What should be monitored in croup and why?
|
Breathing effort and response
Pulse oximetry Level of stridor (discharge once stridor free at rest) |
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|
What are the 3 hallmark symptoms of croup?
|
Hoarseness
Stridor Barking cough |
|
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|
What is croup?
|
Inflammation in the larynx, subglottic airway, trachea
Laryngotracheobronchitis |
|
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|
How do you definitively confirm the diagnosis of CF?
|
CFTR genetic mutation analysis (DNA analysis of common mutations)
Can also do immunoreactive trypsin as a newborn and sweat test (these aren't definiteive) |
|
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|
Why do kids with CF have fatty stools and how do you treat these?
|
Absence of CFTR in apical membrane of pancreatic duct
Failure to secrete Na, HCO3, and water Retention of enzymes in pancreas Destruction of pancreatic tissue No pancreatic enzymes are released Fats cannot be broken down and absorbed so remain in the stool Rx: pancreatic enzyme supplements before all meals Fat soluble vitamin replacement High fat diet Consider PEG tubes if weight loss continues despite aggressive intervention |
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|
Features of CF/obstructive lung disease on examination
|
Clubbing
Use of accessory mm for respiration High respiratory rate Chronic productive cough Haemoptysis Hyperexpansion |
|
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|
Which organisms are common in kids with CF?
|
Psudomonas auriginosa (older kids)
Staph aureus Haemophilus Influenzae |
|
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|
How would you treat the chest infection of a patient with CF?
|
Chest physio
Antibiotics Mucolytics (DNAse) Vaccinations where possible |
|
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|
What is the typical pathological finding in the lungs of patients with CF?
|
Bronchiectasis- dilations of the bronchioles
Hypertrophied mucous glands Mucous secretions |
|
|
|
Pathophysiology of abnormal lung secretions in CF?
|
Abnormal CFTR channel
Blocking of Cl ions moving out to lumen, raised Na absorption from lumen and subsequently drawing in of Cl from lumen due to CFTRs inhibitory regulatory function of Na channel activity Depletion of perciliary layer of water --> thickened mucous Failure to clear mucus Site for colonisation of bacteria |
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|
What are 2 features that indicate CF in spirometry results?
|
An obstructive pattern
Irreversible with bronchodilators |
|
|
|
Describe the pathophysiology of the late lung changes in CF?
|
Continuous coughing and recurrent infections cause the weakened damaged bronchus to balloon out, forming saccular air spaces = bronchiectasis
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|
Describe the dysmorphic features seen here
What do you think could account for these? |
Epicanthal folds
Slanted palpebral fissures Flat nasal bridge Protruding tongue Down syndrome |
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|
What dysmorphic facial features do children with down syndrome have?
|
Round face
Flat nasal bridge (maxillary hypoplasia) Upslanting palpebral fissures (separation between the upper and lower eyelids) epicanthic folds (skin fold of the upper eyelid covering the inner corner of the eye) Small mouth/prodtruding tongue Small ears Flat occiput Short neck Brushfield spot (small white or greyish brown spots on the periphery of the iris due to aggregation of connective tissue) |
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|
Characteristic dysmorphic features in the extremities of children with down syndrome
|
Short broad hands
Hypoplastic mid phalanx of fifth finger Incurved fifth finger (clinadactyly) Transverser palmar crease Space between the first and second toes (sandal gap deformity) Hyperflexibility of joints |
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|
Name the 3 abnormalities in these photos
|
Epicanthic folds
Transverse palmar crease Space between first and second toe "sandal gap" |
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|
Name the congenital defects associated with Down syndrome
|
Congenital heart disease
Duodenal atresia Hirschprungs Cataracts Strabismus Imperforate anus Oesophageal atresia |
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|
What investigations are done to confirm down syndrome?
|
Ultrasound 11-13 weeks (nuchal translucency)
Maternal serum (triple enzyme test) Amnio (14-18 weeks) Detection of trisomy 21 (chromosomal analysis FISH, karyotype) |
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|
Which vaccines are given at 4 months?
|
Hep B
DTPa Hib Inactivated poliomyelitis Pneumococcal conjugate Rotavirus |
|
|
|
Pre-vaccination history
|
Previous vaccinations - any adverse side effects
Allergies, particularly to any part of the vaccine Illnesses (current and past) Immunodeficient (including taking high dose steroids) Is the child sick at all, fever > 38.5 Does child live with anyone who is immunosuppressed/unvaccinated |
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|
Adverse effects
|
Less severe
Irritation, local inflammation, mild fever More severe anaphylaxis (pneumoccocus), encephalopathy |
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|
Contraindications to immunisations
|
Previous allergic reaction to the vaccine or any component of the vaccine
Live vaccines should not be administered: - immunosuppressed (this includes being on high dose steroids) - when pregnant - Pregnant women need to avoid getting pregnant within 4 weeks of a vaccine |
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|
What would you do if the child had an anaphylactic reaction while the vaccine was being given?
|
ABC
IM adrenaline - if patient is not improving repeat every 5 mins until patient does improve (0.01ml/kg of 1/1000) O2 Call for help NB: lay patient flat or at 45 degrees if breathing is difficult All patients should be admitted to hospital |
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|
How long do you observe the child after giving them a vaccine before letting them leave the clinic?
|
15 mins
|
|
|
|
Where would you give a child an injection? How would you position them?
|
Give the injection in the anterolateral thigh
Young children: position them on Mum/Dad's lap with the parents arms hugging them close - infant's arm should be restrained against the parent's chest, parent restrains leg that is flexed Older child can be the same position or straddle Mum or Dad |
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|
Which vaccines are given at 6 months?
|
Hep B
DTpa Hib Inactivated polio Pneumococcal conjugate Rotavirus NB: same as 4 months |
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|
Which vaccines are given at 12 months?
|
Hep B
Hib MMR Meningococcal C |
|
|
|
How often is DTPa given?
|
2, 4, 6 months
booster at 15 years |
|
|
|
How often is Hep B given?
|
Birth
2 months 4 months 6 months 12 months |
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|
How often is Hib given?
|
2, 4, 6, 12 months
Same as Hep B except not at birth |
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|
What type of needle should be used to give an IM vaccine?
|
23 or 25 gauge
25 mm in legnth |
|
|
|
Which vaccines need to be administered subcutaneously?
|
Inactivated polio
Meningococcal Varicella |
|
|
|
Which type of needle should be used to give a subcutaneous injection?
|
25 or 26 gauge
16 mm in length |
|
|
|
What is involved in a septic work-up?
|
Blood count and film
Blood cultures CXR UA Stool culture/faecal WCC Lumbar puncture |
|
|
|
Indications and contraindications for an LP
|
Indications:
Meningitis or encephalitis Contraindications: Raised ICP: focal signs (CN palsy 4 and 6), vomiting, headache worse on lying down, hypertension, bradycardia, irregular respiration (cushing's reflex), confusion, decreased level of consciousness, spinal cord and tethering, bleeding disorder, local infection |
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|
Explain lumbar puncture procedure to Mum
|
Explain procedure to child
Use LA if able to Wash hands Sterile - gown and glove Position child in lateral position, thoracolumbar spine well flexed, avoid neck pflexion (sitting forwards (don't want twist in spine) Swab area with alcohol Line up iliac crests L4/L5 Want to go in at L4/L5 or L3/L4 21 gauge cannula Take 3 tubes (10 drops in each tube) Send to lab to look for cell count, glucose, protein, smear and culture |
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|
Risks involved with LP
|
Coning
Infection Bleeding |
|
|
|
What does
low glucose High protein Neutrophils suggest about the CSF |
Bacterial meningitis
|
|
|
|
What does lymphocytes
Normal glucose Protein normal or raised suggest about the CSF? |
Viral meningitis
|
|
|
|
What are the usual organisms in meningitis in children > 2
|
Strep pneumoniae
Neisseria meningitis Haemophilus influenzae type b |
|
|
|
Treatment of meningitis
|
Dexamethasone +
> 2 months - cefotaxime 4 weeks - 2 months - cefotaxime, benzylpenicillin and gentamicin < 4 weeks same as above but no dexamethasone |
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|
If CSF gram stain is grame +ve which organism?
Gram -ve which organism? |
Gram +ve - strep
Gram -ve - meningococcus |
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|
In meningitis which organisms are sensitive to which antibiotic
|
N meningitis and s. pneumoniae are sensitive to benzylpenicillin (some say add vancomycin if strep)
Haemophilus influenza type B is cefotaxime |
|
|
Describe the abnormalities here
How would you treat this? |
Otitis externa
Thick clumpy otorrhea Oedema of the ear canal Fungal overgrowth Treatment: Remove debris by swabbing or syringing Topical drops, creams or ointments Sofradex, ciproxin-hydrocortisone Systemic antibiotics if acute localised or acute diffuse cellulitis |
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|
Child less than 2 presents with fever and pulling at one of her ears. What further questions do you want to ask in the history?
|
When did these symptoms start?
How high is the fever? Any other symptoms Recent URTI? Ear discharge Swimming recently Neck stiffness Have you been cleaning her ears out with cotton buds |
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|
After taking a history from a 2 year old with suspected otitis media and a fever what examination would you do?
|
You need to do a thorough physical examination to look for the focus of the fever
Respiratory exam ENT exam with otoscopy, Rinnes and weber Complete head to toe examination - looking for focus on infection |
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|
What are the typical pathogens that are found in otitis media?
|
90-95% bacteria
Strep pneumonia Haemophilus influenza Moraxella catarrhalis 5-10% virus RSV, rhinovirus |
|
|
|
What are the complications of acute otitis media?
|
Perforation of the tympanic membrane (purulent otorrhea and usually relief of pain)
Febrile convulsions Suppurative complications: mastoiditis, suppurative labrinythitis, intracranial infection (meningitis, extradural or subdural abscess or brain abcess) - very uncommon Benign intracranial hypertension Facial nerve palsy Lateral sinus thrombosis |
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|
How would you treat a perforated ear drum?
|
Swab the ear for culture and sensitivities
In the mean time treat with amoxicillin until sensitivities come back Try to keep dry Paracetamol or ibuprofen for the pain |
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|
How would you treat someone with otitis media but no perforation?
|
Usually resolve on their own so can adopt watchful waiting
Antibiotics of no benefit - benefit doesn't outweight risk Can give if symptoms don't start to resolve within 24-48 hours Paracetamol 20-30mg/kg for pain relief |
|
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|
How would you treat someone with chronic otitis media?
|
Observe and verify hearing assessment
Antibiotics if not already given Consider grommets |
|
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|
Child with chronic otitis media. Mother is concerned about the child's hearing being affected. What do you do?
|
Reassure mother
Arrange audiogram testing Refer to ENT specialist |
|
|
|
What are the risk factors for deafness?
|
Hereditary
Congenital infections (CMV, syphillis) Prematurity,hypoxia, prolonged difficult labour Infection in childhood (MMR) Traumatic fracture of the petrous bone Chronic otitis media Meningitis |
|
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|
What does the ear look like in a patient with acute otitis media?
|
Usual middle ear landmarks are not well seen (handle of malleus, incus, light reflex)
Tympanic membrane is dull and opaque and may be bulging |
|
|
|
Which questions should be asked when deciding if the systematic review is applicable to my patient?
|
Is the study population similar to my patient?
Clinically important outcomes considered Benefits vs harm Can the results be applied to my patient |
|
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|
How do you evaluate the methodology of a systematic review?
|
Was there a clear well formulated question?
Is it unlikely that important, relevant studies were missed Were the criteria used to select articles for inclusion appropriate Are the results reproducible? Thorough search for papers Appropriate papers included with no language, or publication bias Were the included studies sufficiently valid for the type of question asked? Were the results similar from study to study? |
|
|
|
Why are young children more susceptible to otitis media?
|
Children's eustachian tubes don't work very well. 2 main functions of eustachian tube -aeration (to allow bones to vibrate and trasmit sound) and drainage
In children - doesn't drain - relatively short, broad face of the child - eustachian tube has horizontal access. Open jaw, yawn, swallow, mm attached to eustachian tube - open it up. Palatal mm mechanics don't work so well in children - not as strong |
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|
|
When can you take a collar off a trauma patient?
|
Normal set of films
Clear clinically - log rool and palpate spine - Free of pain anywhere - no decreased concsiousness Common site to miss injuries: scalp, neck, back, perineum, hands |
|
|
|
What vaccines are given at 18 months?
|
Varicella
|
|
|
|
What is a febrile seizure?
|
It is a brief generalised convulsion (< 10 mins) in a febrile child (> 38 )aged between 6 months and 6 years with no previous afebrile seizures, no progressive neurological disease and no evidence of CNS infection
It is usually associated with a viral illness Common 3-5% of all children M>F Counsel parents: febrile seizures do not cause brain damage, very small risk of developing epilepsy 9% (if multiple risk factors); 2% (with febrile simple seizures compared to 1% general population) , NB: it does not recur within a 24 hour period |
NB: it is thought to be associated with an initial rapid rise in temperature
|
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|
What is the most common cause of seizures in childhood?
|
Benign febrile seizures
|
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|
|
What would you look for on initial examination of a child with a suspected febrile seizure?
|
LOC
Source of infection - rash, UTI, respiratory, ears, eyes, mouth Signs of meningitis Fever Neuological exam |
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|
If a child has a seizure in front of you what are the 4 most important things that you must do?
|
Airway
Breathing Circulation Disability - blood glucose, pupils, GCS |
|
|
|
Differential diagnosis of seizures in childhood?
|
Benign febrile seizure
hypoxic ischaemic encephalopathy (aspyhxia) intracranial haemorrhage, trauma Hypoglycaemia, hypocalcamia, hyponatraemia CNS infection Epilepsy Tumour Drugs |
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|
What questions do you want to ask on history of a child with a seizure?
|
Did you witness it
How long did it last Did they lose consciousness Have they had these before Trigger Was there any warning Symptoms of infection? Fever Vomiting, diarrhoea Rash |
|
|
|
What investigations are warranted in a seizure?
|
If simple febrile seizure investigations unnecesssary except for determining the focus of fever
Can do: FBC, EUC, calcium, magneusium, glucose Septic work up strongly recommended in all children < 6 months, older children with longer seizures, any signs of meningitis Toxicology screen - if indicated EEG, CT, LP - if indicated (nonfebrile, continuing seizures, focal aspects to seizures) EEG - if first time nonfebrile seizure |
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|
When would you consider doing an EEG or MRI to investigate seizures
|
MRI or EEG if
- nonfebrile seizure - continuing seizures - focal aspects to seizures EEG not warranted unless complex febrile seizure or abnormal neurological findings |
|
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|
How should parents handle a seizure in their child?
|
There is nothing you can do to make a convulsion stop - stay calm and don't panic
Place child on soft surface on back or side Do not restrain child Do not put anything in their mouth including fingers (your child may choke and swallow their tongue) Try to watch exactly what happens so that you can describe it later Try to time the convulsion If the convulsion stops in less than 5 mins - see GP ASAP if convulsion lasts longer than 5 mins - AMBULANCE |
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|
Management of seizures in hospital?
|
If unwitnessed or duration > 5 mins give benzodiazepine PR and wait 5 mins
If it continues give another benzodiazepine and wait 5 mins If still continuing give phenobarbitone or phenytoin over 30 mins |
|
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|
What dose of paracetamol do you give to a child?
|
15mg/kg/dose
max 4 doses/day |
|
|
|
What dose of NSAIDs do you give to a child?
|
10mg/kg/dose
Every 6-8 hours |
|
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|
What dose of oxycodone do you give to a child?
|
0.1-0.25mg/kg/dose
every 4 hours |
|
|
|
What are the equivalent oral doses for IV morphine?
|
20mg IV morphine = 60 mg oral morphine
|
|
|
|
With a history of failure to thrive what questions would you want to ask?
|
What are they eating? Fluids, solids?
How long have they been losing weight for? Vomiting, diarrhoea (blood, mucous, colour etc) Urinary problems Family history Recent illness What is their weight, height, HC? How's mum going, social problems |
|
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|
What age should infants start solids?
|
At 6 months of age, can start at 4 months
Milk is still the most important part of the diet Baby may show signs by wanting to put things in their mouth Able to suck small amounts of pureed food from a spoon Interested in food eaten by others More frequent feeding Can sit upright when supported with good control of the head and neck |
|
|
|
What are the fat soluble vitamins?
Describe the deficiency syndrome |
Vitamin
A: night blindness D: rickets, osteopenia E: peripheral neuropathy and ataxia K: coagulopathy |
|
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|
What should you look for on the exam of a malnourished child?
|
Height, growth, weight
Evidence of specific micronutrient deficiency: pallor, bruising, bleeding, skin, hair, gum abnormalities, neurological, ophthalmological disorders, angular stomatitis (Fe deficiency) Abdo distension Wasting mm (especially buttocks and limb girdle) Clubbing SOB or other signs of illness e.g., heart disease |
|
|
|
How do you figure out the ideal weight of a child?
|
< 8; age x 3 + 7
> 8: age x 3 |
|
|
|
Differentials for malnutrition/failure to thrive in a well fed child
|
Coeliac disease
Cow's milk intolerance CF: meconium ileus, pancreatic insufficiency IBD Heart failure Malignancy Infection (e.g., giardia) Chronic illness |
|
|
|
What investigations should be done for coeliac disease?
|
Anti-transglutaminase (tTG)
- Coeliac's is associated with an increased prevalence of IgA deficiency. tTG is an IgA- detecting test therefore you must order an accompanying IgA level Antigliadin Antiendomysial antibodies (anti-EMA) To confirm - duodenal biopsy (small bowel) after eating gluten diet : shows total villous atrophy |
|
|
|
What does a duodenal biopsy show in someone with coeliac disease?
|
Total villous atrophy
Hyperplastic lengthed crypts More plasma cells and intraepithelial lymphocytes Increased cellularity |
|
|
|
What is the distribution of coeliac disease in the small bowel in terms of severity?
|
Proximal most severe to distal least severe
|
|
|
|
Treatment for coeliac disease?
|
Eliminate gluten from diet for life
Avoid Barley Rye Oats Wheat |
|
|
|
Possible long term complications of coeliac disease if not treated?
|
Malnutrition, failure to thrive
Osteoporosis - vitamin defieciency Small bowel lymphoma |
|
|
|
14 year old: 4 week history of diarrhoea, bloody stools, crampy abdo pain
Differentials |
Coeliac
IBD: Crohn's, ulcerative colitis Lactose intolerance Bacterial gastroenteritis |
|
|
|
What are the features of crohn's disease?
|
Abdominal cramps - post prandial, colicky
Weight loss Diarrhoea Colonic involvement: bloody or mucous stool Systemic symptoms - fever, malaise Fistulas, fissures, abscesses Ileitis may present with post-prandial pain, vomiting, RLQ mass mimics acute appendicitis Extraintestinal manifestations: growth retardation, anorexia, fatigue, delayed puberty, erythema nodosum, arthritis, clubbing, hepatitis, uveitis Mouth ulcers |
|
|
|
Which investigations should be done to confirm the diagnosis of IBD?
|
Endoscopy = gold standard
Gastroscopy and colonoscopy (with ileoscopy) - take biopsies at all levels of the gut |
|
|
|
What would be your immediate management in ED?
|
Nil by mouth
Fluids IV Stool culture Pain management? |
|
|
|
What is the difference between Crohns and Ulcerative colitis?
|
Crohns = inflammatory disease that affects any portion of the gut but most often involves the distal small bowel and colon
Affected areas with normal areas in between them Ulcerative colitis = inflammatory disease limited to the colon and rectum skip lesions not found Granulomas present in crohn's not UC |
|
|
|
What is the intial treatment of IBD?
|
Steroids 1-2mg/kg of prednisolone for moerate to severe IBD - 2-3 months with gradual dose reduction
|
|
|
|
What treatment is used as maintenance for IBD?
|
Enteral therapy
Aminosalicylates: effective in reducing remission in active colitis Sulfasalazine is similar but cheaper Azathioprine (immunosuppressive) effective for remission induction and maintenance therapy (assoc. with significant adverse effects take 3-6 months to achieve their maximal benefit) Methotrexate Antibodies to TNF alpha - infliximab Surgery if growth failure and no response to pharmacological or nutritional therapies |
|
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|
Which drugs are contraindicated in IBD?
|
NSAIDs may worsen IBD
|
|
|
|
Why would you get these in IBD?
Hypochromic normocytic anaemia Low albumin High platelets, neutrophils, lymphocytes |
Chronic inflammatory process not due to bleeding or iron deficiency anaemia
Low albumin because protein losing enteropathy |
|
|
|
Differential diagnosis for anaemia?
|
Microcytic: iron deficiency, thalassaemia,
Macrocytic: B12, folate deficiency Normocytic: haemolysis or blood loss, marrow hypolasia, leukaemia infiltration |
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|
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How do you manage iron deficiency?
|
Correct underlying cause
Dietary advice: Encourge diverse, balanced diet, limit homogenised milk Oral iron therapy 6mg/kg/day elemental iron (ferrous sulphate or ferrous gluconate) Re-check Hb levels after 1 month of treatment |
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Which compensatory features allow in iron deficiency anaemia allowing children to be active and apparently well even with anaemia?
|
Increased CO
Increased production of 2,3-DPG in RBCs High levels of EPO (expan RBC production in bone marrow, high levels of reticulocytes) |
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Give 4 reasons for anaemia in children under 2
|
Iron deficiency
B12 and folate deficiency Thalssaemia G6PD Leukaemia Hereditary spherocytosis Slow bleed - haemangioma Malabsorption |
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What are some reasons why the iron supplementation wouldn't be working for iron deficiency anaemia?
|
Underlying malabsorptive state - IBD, coeliac
Over used Compliance Continual slow blood loss Taken with tea or coffee on full stomach - not absorbed as well |
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2.5 year old pours boiling water down from the stove. What are the two most important things for Mum to do?
|
Stay calm
ASAP remove clothing and place child in under cold shower for at least 30 mins (avoid letting your child get cold while you do this) - Analgesic effect - reduces heat gradient thus decreasing penetration of the heat - Aids in reducing the inflammatory cascade Do not apply ice Call an ambulance if your child has difficulty breathing, is unconcious, has severe pain that you cannot control |
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When assessing a child with burns what would you look for in your initial assessment?
|
Airway and breathing - stridor, hoarseness, black sputum, singed nasal hairs, respiratory distress
Circulation - hypovolaemia, level of dehydration Estimate the size of the burns Estimate whether they are superficial, partial thickness or full thickness - this is difficult to do within the first 24-48 hours |
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How do you assess the size of the burnt area?
|
Rule of 9s
Arms - 9% Head - 18% Trunk - 36% Legs - 14% |
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Give 2 or 3 things that makes assessing a child for burns different from assessing an adult for burns?
|
- Different method of assessing the size of the burns
-Takes only 1 second for child to burn to cause damage (due to skin thickness) - Child have a greater surface to mass ratio - Thinner skin - Lower level of glucose stores therefore unable to compensate |
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What are some complications of burns?
|
Hypovolaemia, oliguria,
Failure or delay in healing of the burn or donor site due to infection and/or underlying catabolism Hypertrophic keloid scar Compartment syndrome - ischaemia Hypomotility of the gut |
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What immediate treatment would you do for a child with burns who presents to ED?
|
Analgesia (paracetamol 20-30mg/kg PO or PR; codeine 0.5-1mg/kg PO; morphine 0.1mg/kg IM or 0.05-0.1mg/kg IV)
Fluids (Hartmann's solution 2 -4ml/kg/%BSA; 1/2 in first 8 hours after burn - maintenance 5% dextrose and NS; aiming for urine output 1ml/kg/hour) Bloods (Hb, Hct, EUC, glucose, group and hold) Dressings |
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What is the main complication of first aid for burns?
|
Hypothermia
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If mum askes you how deep are my child's burns - how do you answer?
|
It is very difficult to assess the depth of the burns particularly within the first 24-48 hours. Every burn is different.
Many people have made the mistake of telling parents that their child's burns are superficial, which gets their hopes up and then later have to tell them that they are in fact deep. For this reason we don't try to make estimates of the depth of the burns for at least 48 hours. Even then it is difficult to make an accurate assessment of the depth. |
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If a kid has a skin graft for a burn, why would a NGT be inserted, why would the arm be splinted?
|
NGT - aggressive nutritional support to improve healing
Splints - prevent contractures |
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What is the long term management for burns?
|
Physio - maintain joint mobility, prevent contractures, intiate scar management
- exercises, splinting, pressure, Emotional support - Social worker and counseller Surgery may be necessary to assist cosmetically as they age |
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What are contractures in burns?
|
Hypertrophic scars that form over joints that decrease range of motion
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What is an escharotomy?
|
Full thickness circumferential burns can cause a torniquet effect. Increased blood viscosity, localised oedema and reduces blood volume can lead to venous stasis and ischaemia.
An escharatomy avoids this possibilty/reduces the tension by cutting the skin with a scalpel. Skin is left open and covered with a dressing |
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Effects of a burn injury on the body systemically
|
Bronchoconstriction
Reduces myocardial contracility Increased capillary permeability --> hypovolaemia Basal metabolic rate threshold increased Reduces immune response Peripheral and splanchnic vasoconstriction |
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When should a child with a burn be transferred to Westmead?
|
if > 5% TBSA
Respiratory burn Burn of specialist areas - hands, feet, perineum Concomitant trauma Pre-existing illness |
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What is hirschsprung's disease?
|
Congenital aganglionic megacolon
= failure of normal innervation of the distal colon by the ganglion cells of the myenteric plexus Colon remains contracted and impairs fecal movement |
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Clinical features of hirschsprung's disease?
|
Typically only rectosigmoid involvement but may extend to entire colon
No meconium within first 24 hours Palpable stool on abdominal exam with empty recum on digital rectal exam Intermittent diarrhoea, BM only with rectal stimulation Constipation, abdominal distension Vomiting, failure to thrive |
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What are the complications of hirschsprung's disease?
|
Enterocolitis: may be fatal
toxic megacolon and perforation |
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How do you diagnose hirschsprung's disease?
|
Abdominal x-ray - cannot see gas in rectum
Barium enema: proximal dilation due to functional obstruction, empty rectum Manometric studies: shows failure of anal sphincter relaxation, may have false positives rectal biopsy: definitive diagnosis (absent ganglion cells) |
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Treatment of hirschsprung's disease
|
nonsurgical is short segment: increase fibre and fluid intake, mineral oil
Surgical: excision of the anganglionic segment and re-anastomosis of the ganglionated bowel to the anus |
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What is the most common cause of neonatal bowel obstruction?
|
Hirschprung's disease
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At what age do patients with Hirschsprung disease commonly present?
|
3-4 days of life
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What is meconium ileus?
|
It occurs in kids with CF
Meconium becomes excessively thick and tenacious, causing obstruction and the distal ileum is jammed with hard pellets of inspissated meconium The colon is empty and no meconium is passed after birth The infant has a distended abdomen and commences vomiting shortly after birth |
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How is meconium ileus confirmed?
|
Contrast enema demonstrates a microcolon
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What are the features of meconium ileus on X-ray?
|
Mechanical obstruction in the ileum, below this level is an empty and narrow microcolon, above is loops of hypertrophied bowel with fluid
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What are the features of duodenal bowel obstruction?
|
Bile stained vomiting soon after birth
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What are 2 causes of duodenal bowel obstruction?
|
Duodenal atresia
Malrotation with volvulus |
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What are the clinical features of duodenal atresia?
|
Associated with Down syndrome, prematurity, Imperforate anus
Infants are usually alert and feed well but vomit bile stained material immediately There is no abdominal distension |
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How do you diagnose duodenal atresia?
|
Plain x-ray of the abdomen which reveals a double bubble sign - gas in the stomach and proximal duodenum
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Treatment of duodenal atresia?
|
Duodenoduodenostomy after correction of any fluid and electrolyte disturbances
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Causes of vomiting in the neonatal period
|
Sepsis - meningitis, UTI, septicaemia
Pyloric stenosis (day 10) Duodenal atresia or malrotation with volvulus Obstruction beyond the duodenum e.g., Hirshsprung's, meconium ileus Strangulated inguinal hernia Hypoglycaemia Transoesophageal fistula |
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Causes of vomiting in infancy?
|
Infectious and inflammatory: GI, UTI, OM, meningitis, pneumonia
Obstruction: Intussuception, volvulus, pyloric stenosis, strangulated inguinal hernia GORD Cow's milk intolerance, coeliac, IBD Increased ICP DKA |
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What medical interventions should be done preoperatively before for e.g., a procedure to fix duodenal obstruction?
|
Fluids
Group and hold Nil by mouth Prophylactic antibiotics Urinary catheter Informed consent |
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How do you assess the severity of the burn?
|
Size
- rule of 9s - hand is 1% Depth - appearance changes with time - history is useful Site - airway demands admission - hands and feet need special care - perianal and face - usually don't require admission |
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6 year old, MVA - speeding, no seatbelt
What questions do you want to know in the ambulance on the way to the hospital? |
ABC
AVPU (GCS) Obvious injuries Where is next of kin? |
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6yr old, speeding MVA, no seatbelt
First 4 things to assess? |
Airway control and c-spine
Breathing and ventilation Circulation and control of haemorrhage Disability and neurological examination Environment and exposure |
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What is different about ensuring an adequate airway in children compared to adults?
|
Large cranium --> head flexes when body lies flat --> tends to buckle airway
Use blankets under shoulder 4-6 months are nasal breathers Large tongues Small face, mandible Cephalad larynx |
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Can you do a crico-thyroidotomy in children?
|
No
Children don't have a crico-thyroid membrane (there is no space to insert the tube) Instead can use a thin needle which allows you to O2 the child but not ventilate - can buy you some time (20 mins) but eventually child will get hypercarbic |
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Why will children get early fatigue with increased work of breathing?
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Ribs are more horizontal therefore less expansion - cannot increase capacity - fatigue more quickly
Fewer type 1 fibres - early fatigue Thin chest wall Therefore must support with O2 |
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What is the commonest cause of cardiac arrest in a child?
|
Hypoventilation
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What % diminution in blood volume is necessary to manifest minimal signs of shock?
|
25%
Children have an increased physiological reserve |
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What is the blood volume of a child?
|
80ml/kg
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What are some signs of shock in a child?
|
Tachycardia
Narrow pulse pressure Decreased level of consciousness If they are hypotensive that means they have lost 45% of their volume |
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How do you figure out what a normal systolic and diastolic BP should be?
|
Systolic BP = 80 + twice age in years
Diastolic = 2/3 systolic |
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|
What is the average urine output for
< 1 year Toddler Older child Adult |
< 1 year - 2ml/kg/hr
Toddler 1.5ml/kg/hr Older child 1ml/kg/hr Adult - 0.5ml/kg/hr |
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What does AVPU stand for?
|
Alert
Voice Pain Unresponsive |
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What presentations make you think of battered baby?
|
Multiple subdurals without fracture
Retinal haemorrhage Perioral injuries Ruptured viscera without blunt trauma Genital/perianal trauma Old scars, healed fractures Bites, burns, rope marks |
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What is a normal RR and HR for a term baby, 3 months, 6 months?
|
Term baby
RR = 40-60; HR = 100-170 3 months RR = 30-50; HR = 100-170 6 months RR = 30-50; HR = 100-170 |
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What is a normal RR and HR for a 1 year, 2 year, 5 year old?
|
1 year
RR = 30-40; HR = 110-160 2 year RR = 25-35; HR = 100-150 5 years RR = 25-30; HR = 95-140 |
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What is a normal RR and HR for a 5-12 year old?
> 12 |
5-12
RR = 20-25; HR = 80-120 >12 RR = 15-20; HR = 60-100 |
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Is developmental dysplasia of the hip more common in females or males?
|
Females
6:1 |
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What are the RF for developmental dysplasia of the hip?
|
Family history
Breech birth - at time of delivery or prior to delivery First born - uterus is more rigid Packing - fetus has been squashed, commonly due to relative lack of amniotic fluid |
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What are the clinical features of developmental dysplasia of the hip?
|
Asymmetrical hip creases (soft sign 30% of DDH babies = N)
Shortening Limited abduction in flexion Barlow's test (trying to dislocate hip - flex hip to 90 then push down) Ortolani's test (trying to reduce dislocated hip) - abduct hips and push up to try to push femoral head into acetabulum |
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How do you diagnose developmental dysplasia of the hip?
|
Best screening is clinical exam
Under 6 months - ultrasound (movement can see femoral head dislocating) After 6 months - X-ray |
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Indications for investigations into developmental dysplasia of the hip?
|
Family history
Breech abnormal clinical signs |
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How do you treat developmental dysplasia of the hip?
|
Closed reduction (easy in < 6 months) - brace in flexion and abduction
Open reduction - brace in flexion and abduction (if > 12 months) Acetabuloplasty (if > 18 months) - surgically reshape acetabulum NB: if > 3 years - no remodelling potential therefore increased period of wearing the brace |
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What is the differential diagnosis for a 4 year old boy with 2 day history of limp, hip pain and stiffness?
|
Transient synovitis (= self limiting viral inflammation - usually post viral infection)
Septic arthritis (sick) Perthes disease (very well) |
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What age group is transient synovitis found in?
Is it more common in males or females? |
Age 2-5 years
More common in males 3:2 |
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What is the treatment for transient synovitis?
|
Neurofen
Rest |
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What are the symptoms of transient synovitis?
|
Pain
Limp Stiffness Trendelenberg |
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|
What is perthes disease?
|
Idiopathic avascular necrosis of the femoral head
Unknown cause - takes a few months to present |
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|
What age group is perthes disease common in?
Is it more common in males or females? |
4-10 years
Males 4:1 |
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Symptoms of perthes disease
|
Limited hip abduction
Limp Positive trendelenburg test |
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|
Treatment of perthes disease?
|
Containment
Keep femoral head in acetabulum non-operative - brace operative - pelvic osteotomy, femoral osteotomy |
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What are some bad prognostic factors for children with perthes disease?
|
Late age of onset > 8
Whole head involvement Lateral subluxation |
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|
Symptoms of slipped capital femoral epiphysis
|
50% of children present with only knee or thigh pain
Obesity Pain Limp Out-toeing |
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|
Common age for presentation of slipped capital femoral epiphysis
|
Males 12-15
Females 10-13 |
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|
What are some aetiological factors of slipped capital femoral epiphysis?
|
Obesity
Trauma Physiological |
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|
What is the prognosis of slipped capital femoral epiphysis?
|
Osteoarthritis age 50
50% will need total hip replacement |
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|
Explain to Mum what a bone scan entails?
|
Nuclear scanning test to find abnormalities in the bone that are triggering healing (i.e. sensitive to areas of unusual bone remodelling)
Patient is injected with a small amount of radioactive material and then scanned with a gamma camera (sensitive to radiation emitted by the material) |
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|
Describe the developmental milestones involved in hearing
|
Responds to bell at 2 months
Turns to bell at 4 months Can isolate stimulus above head at > 8 months Older child: can whisper in ear and see if repeats words |
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At what age can a child:
Sit unaided? Jump? |
Sit unaided at 6 months
Jump at 3 years |
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At what age can a child sit in a prone position head to 90 degrees?
|
3 months
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|
At what age can a child roll over?
|
4.5 months
|
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|
At what age can a child stand and weight bear?
|
6 months
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|
At what age can a child walk?
|
12 months
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At what age can a child go up steps?
|
2 years
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At what age can a child
Jump Stand on one foot Hop |
Jump: 3 years
Stand on one foot: 3.5 years Hop: 5 years |
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At what age can a child:
Grasp a cube Transfer across midline Bang 2 cubes together |
Grasp 5 months
Transfer across midline 6 months Bang 2 cubes together 12 months |
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At what age can a child
Palmar grasp Thumb finger grasp |
Palmar grasp - 6 months
Thumb finger grasp - 12 months |
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At what age can a child use a raisin
Thumb finger Neat pincer |
Thumb finger - 11 months
Neat pincer - 15 months |
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At what age can a child use a crayon to
scribble copy line circle cross |
scribble - 2
Copy line - 3 years Circle - 3.5 Cross - 4.5 |
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At what age do babies start vocalising?
|
2-3 months
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At what age do babies babble?
|
6 months
|
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At what age to babies imitate sounds?
|
12 months
|
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|
At what age should a child be saying 6 words
|
18 months
|
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|
At what age should a child be able to say 2-3 word sentences?
|
24 months
|
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|
At what age do children know the plural and colour?
|
Plural - 3 years
Colour - 4 years |
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|
At what age should children first smile?
|
2-3 months
|
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|
At what age should children show likes and dislikes?
|
6 months
|
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|
At what age do children play peek a boo?
|
9 months
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|
At what age will a child come when called?
|
12 months
|
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|
At what age will a child drink from a cup and use a spoon?
|
Drink from a cup - 16 months
Use a spoon - 24 months |
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|
What are 3 language milestones that a child should have at 36 months?
|
Talk in 2-3 word sentences
Can link up sentences with words such as 'and' They can understand and talk about colours, shapes, sizes and where things go They are able to follow instructions with 3 key words "touch your nose' They can have a very simple conversation They like to look at books with an adult and point to pictures |
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At 36 months which gross motor skills should a child have?
|
Jump up
Throw a ball overhead Balance each foot 1 second |
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At 36 months which fine motor skills should have child have?
|
Build a tower of 6-8 cubes
Imitate a vertical line |
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At 36 months what social skills should a child have?
|
Wash and dry hands
Name friend Put on clothing starting to be able to put on t-shirt |
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A 36 month old child presents to the GP with only 3 words. Parents are worried. What further history do you need to know?
|
Is it just language delayed?
What are gross and fine motor and social skills like Past medical history - infections (ear), congenital and post natally Immunisations Medications Family history Have the been progressing normally up until this point or have they always been delayed Normal birth and delivery Premature? |
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|
What are 4 differential diagnoses for speech delay in a child?
|
Autism
Hearing impairment Cognitive disability Cerebal palsy Anatomical problems of the mough - cleft palate, cranial nerve palsy |
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|
What are some features of language delay due to hearing impairment?
|
Language may seem normal for up to 6 months (including cooing and babbling) but may regress due to lack of feedback
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|
How do you evaluate hearing loss in children?
|
< 6 months: auditory brainstem response: tympanometry (impedance testing), evoked potentials
> 6-8 months: behaviour audiometry >3-4 years: Pure tone audiometry |
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|
What investigations would you do in a child with language delay?
|
Check hearing
FBC, TFTs, EUC, lead or metabolic levels Refer to speech therapist |
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|
What are some causes of global devepmental delay?
|
Down sydnrome
Cerebal palsy Fragile X Autism Intrapartum asphyxia Metabolic disorders (inborn errors of metabolism, hypothyroidism) CNS abnormalities (meningitis/encephalitis, TORCH infections, structural) |
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|
What 4 assessments are done by various people to assess developmental delay?
|
Neurodevelopmental
Hearing Psychosocial evaluation Occupational therapy and/or physiotherapy Genetics consultation Language assessment |
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|
What is tympanometry?
|
Provides a graph of the middle ear's ability to transmit or impede sound energy as a function of air pressure in the external canal
|
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|
When are otoacoustic emissions reduced?
|
Reduced or absent with various dyfunction in the middle or inner ears
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|
Dental trauma, 7 year old crashes bike and breaks 2 teeth what do you want to know over the phone?
|
Mechanism of injury including associated injuries
How many teeth? - how are they broken Previous dental history Time since injury Avulsion (complete displacement of permanent tooth from socket) is a medical emergency |
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|
What should you advice with regards to management of the teeth?
|
If they have been completely knocked out clean with milk and put them back in ASAP and see a dentist ASAP
If you can't put it back in, try to find dental fragments and - put it in milk |
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|
The child is admitted to hospital. What is your immediate management?
|
ABC, including control of major bleeding
Pain relief Fluids Antibiotics? |
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|
What injuries, dental or orofacial are associated with dental trauma?
|
Periodontal/displacement injuries
Dental hard tissues (fractured teeth) Injuries to supporting bone - Fractures (skull, mandible) Injuries to gingiva and oral mucosa - Mucosal lacerations Head trauma Nasal Ear trauma |
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|
In a child who has hit their head, what are you looking for
|
Signs of raised ICP
Cranial nerve palsies Pappiloedema Focal neurological signs Decreased level of consciousness Vomiting |
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|
Common causes of poor dental health?
|
Sugary drinks and food
Poor oral hygiene Honey on the dummy Bottle to bed |
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|
What investgiations should be done in dental trauma case
|
Orthopantogram if considering fractured mandible to TMJ injury (taken extraorally)
CXR - if worried about aspirated tooth Occlusive views (dental x-rays) |
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|
|
4 causes of dental injuries
|
Sport
MVA NAI Walking while learning to walk |
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|
2 forms of prevention of dental and head injuries
|
Mouth guard
Helmet Seat belt |
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|
Why are babies prone to regurgitation?
|
They are born with a loose oesophageal sphincter
This slowsly tighens over time Most outgrow regurgitation by 1 year of age |
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|
When does reflux become pathological?
|
When there is poor growth
If it is blood stained If there are breathing difficulties Crying and irritability uncommonly caused by reflux |
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|
What investigations can be done for GORD?
|
Oesophageal pH monitoring (measures acid in oesophagus over 24 hr)
Gastroesophageal scintigraphy or 'milk scan' Barium meal - not very specific for GOR and results affected by way test is performed, useful for excluding mechanical obstruction e.g., malrotation Endoscopy and biopsy - used to diagnose GORD with oesophagitis or oesophagitis due to other causes e.g., eosinophillic |
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|
Treatment for reflux?
|
No treatment required for most children
Thickened feeds (evidence to improve sx) Positioning (little evidence) Metaclopramide (benefit but risk of harm) PPI (use if suspected oesophagitis) |
|
|
|
What types of lactose intolerance are there?
|
Primary lactase deficiency
Relative or absolute absence of lactase Develops in childhood - uncommon < 2 years of age Secondary lactase deficiency Results from small bowel injury e.g., gastro, bacterial overgrowth, chemotherapy Congenital lactase deficiency Extremely rare Would not survive without lactose free human milk substitute Developmental lactase deficiency Relative lactase defieicncy Observerd in infants < 34 weeks gestation) |
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|
Diagnosis of lactose intolerance
|
2 week trial on strict lactose free diet - resolution of symptoms? Recurrence after lactose reintroduced?
Subtle cases: Hydrogen breath test, stool (pH and faecal reducing substances) Intestinal biopsies (measure lactase activity in the gut) Stool specimen looking for giardia or cryptosporidium Antibodies for coeliac disease - ttg, total IgA, antigliadin |
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|
Management of lactose intolerance
|
lactose free formula in infants
Continue to breast feed Avoidance of milk and other dairy products in children Make sure diet contains adequate calcium |
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|
Differential diagnosis for frothy stools in the breastfed infant
|
Relative lactose malabsorption
Oversupply (feed from one breast only for a few feeds) Not allowing baby to fully feed from one breast causes excess carbohydrate rich fore milk and not enough fat rich hind milk to be consumed (hind milk slows absorption and allows time for digestion) - advise baby to fully feed from one breast Congenital lactose intolerance is very rare and therefore change to lactose free formula is not generally indicated |
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|
What % of body weight is it common to lose after birth?
|
10%
|
|
|
|
How much weight gain do you expect in
newborns- 3 motnhs? 3-6 months 6-12 months |
newborns - 3 months - 30g/day - 200g/week
3-6 months - 20g/day - 140g/week 6-12 months - 10g/day - 70g/week Expect to double birth weight by 4 months, triple by 1 year |
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|
What is motilium?
|
It is a type of galactagogue, domperidone
|
|
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|
How many times a day does 1 week old baby poo?
|
4 times
This reduces to once a day by 2 years of age It is normal for some breastfed babies not to have stools for several days or even longer |
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|
Which symptoms are commonly associated with teething:
biting drooling high fever gum rubbing irritability diarrhoea decreased appetite for solids rashes other than on face mildly raised temperature |
Associated:
Biting, drooling, gum rubbing, irritability, decreased appetite for solids, mildly raised temperature not associated High fever, vomiting, diarrhoea, rashes other than on face |
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|
What is positional plagiocephaly?
|
Posterior skull flattening, uni(males, right side, present from birth)/bilateral (postnatally)
Ipsilateral frontal bulge Forward displacement of ipsilateral ear Parallelogram appearance of skull from above Gradual improvement in head shape over next 2 years |
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|
|
Differential diagnosis of positional plagiocephaly
|
Carniosynostosis: premature fusion of one or more cranial sutures (palpable ridging over fused suture, compensatory overgrowth of other sutures, can be associated with raised intracranial hypertension, developmental delay)
Congenital muscular torticollis |
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|
What is the difference between primary and secondary nocturnal enuresis ?
|
Primary - never dry for more than a few months
Secondary - was dry for 6 months and then wets again |
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Management of nocturnal enuresis
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Bed wetting alarms
Desmopressin - reduces number of wet nights but effect not sustained (advise child not to drink more than 240ml of fluid in the evening of the treatment to prevent water intoxication) NB: restricting fluids before bed and waking during the night does not work |
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At what age is toilet training usually accomplished?
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2.5 years
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What is the most common cause of constipation in children?
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Functional constipation
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What is the difference between type 1 and type 2 constipation
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Type 1: separate hard lumps
Type 2: sausage like but lumpy |
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What is functional constipation?
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Painful bowel motions --> withoholding stool to avoid unpleasant defectation
Caused by toilet training, changes in routine or diet, stress, illness, unavailability of toilets or child too busy It may lead to soiling and eventually abdo distension, cramps and reduced oral intake |
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Management of functional constipation
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Education
- Soiling not intentional - Parents should be positive and supportive Disimpaction - oral and rectal medication > 1 year: lactulose, mineral oil or glycerine suppository < 1 year: prune juice, lactulose, glycerin suppository Maintenance therapy Dietary interventions (increased fluid intake, increased fruit and veg) Behavioural modifications (rewards, time to go to toilet) Medication if necessary |
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How do you calculate the mmol of Na required for a child?
Particularly if the child has acute symptomatic hyponatremia |
(Proposed serum Na - actual serum Na) x 0.6 x weight in kg
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What can happen if you drop a child's Na levels too rapidly?
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Rapid movement of water across the cellular membranes --> cerebral oedema, convulsions, permanent neurological impairment or death
If you are giving fluid you want to bring down the Na slowly - fluid over 24 hours |
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Which % of BSA requires immediate fluid resuscitation
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> 10% BSA
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What are the fluid requirements after a burn
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if > 10% BSA
Hartmann's solution 2-4ml/kg x % BSA with 50% given in first 8 hours from the time of the burn and the other 50% over the next 16 hours + maintenance fluids |
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Why do burns require fluid resuscitation?
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Capillaries at the burn site leak protein-rich fluid immediately after the burn, and this continues for 24 hours. This fluid loss (seen as oedema or exudates on the surface) is maximal over the first 8 hours and reduces in amount over the next 16 hours.
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What are some contraindications to the use of NSAIDs?
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Gastro-intestinal ulceration, ulcerative colitis or Crohn's disease;
Liver dysfunction; Clotting coagulation abnormality or presence, or potential for active bleeding; Severe asthma or acute rhinitis, especially if exacerbated by aspirin; Renal disease, diuretic therapy or situations of decreased renal perfusion e.g. hypotension, hypovolemia; Some orthopaedic procedures, where bone healing may be compromised. |
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Loading dose, maintenance dose, dosing interval
Oral paracetamol |
< 6 months
Loading dose = 20-30mg/kg Maintenance dose = 15-20mg/kg Dosing interval = 8 hours > 6 months Loading dose = 20-30mg/kg Maintenance dose = 15mg/kg Dosing interval = 4-6 hours |
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Dose of oxycodone
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0.1-0.25mg/kg 4 hourly
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What is the typical oral morphine dose
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0.2-0.5mg/kg up to every 4 hours
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How does singulair work?
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Montelukast inhibitor which is a leukotriene receptor antagonist. Leukotrienes are potent bronchoconstrictors that cause airway oedema, stimulating mucous secretion and stimulating eosinophils into the airway.
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What are the potential side effects of inhaled corticosteroids?
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Oral thrush
Growth restriction can be seen - but growth will eventually catch up Impaired glucose tolerance can develop with very high doses - this is rare Adrenal insufficiency is a rare but important side effect of high dose steroids |
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Does bronchodilator response indicate asthma?
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Yes but not exclusively
Can also indicate LRTI bronchiolitis and pneumonia |
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