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37 Cards in this Set

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Causative organisms of pneumonia


(viral, bacterial, and in susceptible children)

RSV, influenza, para-influenza, adenovirus, coxsackie virus


Strept. pneumoniae, Haemophilus influenzae, Staphylococcus, Mycoplasma pneumonae.


In the newborn: group B beta-haemolytic Strept.


In cystic fibrosis pts: Pseudomonas aeruginosa and Staph. aureus

Predisposing factors for pneumonia

Congenital anomaly of the bronchi


Inhaled foreign body


Immunosuppression


Recurrent aspiration (e.g. tracheo-oesophageal fistula)


Cystic fibrosis

Potential complications of pneumonia

Pleural effusion


Septicaemia


Empyema (esp. after Streptococcus pneumonia)


Lung abcess (after Staphlococcal pneumonia)

How is pneumonia diagnosed?

Clinical signs are often not reliable in infants, so CXR should be used to confirm diagnosis.



Compare Mycoplasma and lobar pneumonia.

Mycoplasma pneumonia has a more insidious onset, and requires Erythromycin.




First line Abx for lobar pneumonia is penicillin.

Causative organism of bronchiolitis.

Respiratory syncitial virus




(also adenovirus, influenza, para-influenza)

How is RSV identified in bronchiolytic child?

Nasopharyngeal aspirate can identify RSV using immunofluorescence.

What can be given to infants at high risk of bronchiolitis in the winter months?

Monoclonal antibody (Palivizumab)

What does Bordetella pertussis cause?

Whooping cough.

How can incidence of whooping cough be reduced?

Vaccine! at 2, 3 and 4 months of age

Causative organism of croup?

Para-influenza infection of the upper airways

A child presents with stridor, wheeze and barking cough following coryzal symptoms. What do you suspect?

Croup (acute layrngotrachepbronchitis)

Management of all children with croup involves...

Steroids - single dose dexamethasone (0.15mg/kg) to all children, regardless of severity.




(Prednisolone is an alternative if Dexamethasone unavailable)

Cause of epiglottitis?

Haemophilus influenzae

Why is epiglottitis rare now?

Thanks to the Hib vaccine

How does epiglottitis present?

Children age 2-4


Presents with signs of sepsis & inability to talk or swallow. Children often lean forward to maintain a patent airway and may drool saliva.


---> DO NOT EXAMINE THROAT if epiglottitis suspected!!

How is epiglottitis and croup distinguishable clinically?

Croup - coryzal symptoms precede stridor, wheeze & barking cough. Hoarse voice. Less severe stridor. Para-influenza.




Epiglottitis - affects slightly older children. Sudden onset without preceding coryza, children look acutely 'septic'. Unable to talk, minimal cough. Drooling. Haemophilus influenza.

Management of suspected epiglottitis?

Do not examine the throat.


Needs immediate intubation in theatre by experienced anaesthetist. At laryngoscopy a 'cherry red' swollen epilglottis confirms the diagnosis. Once airway protected, take blood cultures and give IV Abx - Cefotaxime.

What are some causes of cough without breathlessness?

Gastro-oesophageal reflux


Post-nasal drip


Passive smoking


Cystic fibrosis


Tracheo-oesophageal fistula

What the are commonest heart defects? (i.e. what do they cause)

Defects causing a left to right shunt.

What is the most common congenital heart lesion and how may it present?

Ventricular septal defect


If small - asymptomatic


If large - cause SOB on feeding and crying, FTT and recurrent chest infection.


O/E: harsh, rasping pansystolic murmur is heard at the lower left sternal border.


If large defect - cardiomegaly, thrill present, murmur radiates across whole chest. +/- signs of heart failure.

Diagnosis of ventricular septal defect?

Loudness of the murmur is not related to the size of the shunt.


In large defects, CXR shows cardiomegaly and large pulmonary arteries. ECG - biventricular hypertrophy.


ECHO confirms the diagnosis.



Management of ventricular septal defect?

- Abx prophlyaxis until it closes


- Small muscular defects usually close spontaneously


- Large membranous defects w/ HF are initally managed medically, but may need surgery.

What happens if a large ventricular septal defect is left untreated?

The increased pulmonary blood flow can lead to pulmonary hypertension, which eventually leads to reversal of the shunt and intractable cyanosis. This is Eisenmenger's syndrome.

What is Eisenmenger's syndrome?

Obstructive pulmonary vascular disease that develops as a consequence of a large pre-existing left-to-right shunt causing pulmonary artery pressures to increase and approach systemic levels, such that the direction of blood flow then becomes bi-directional or right-to-left. Mega cyanosis.

What age with what temperature of fever would warrant admission to hospital?

>38 C and <3 months


>39 C and between 3 - 6 months

In suspected croup, is a throat examination recommended?

No - even though its not epiglottitis, it still may precipitate airway obstruction and so is to be avoided.

Peak incidence of croup occurs at what age?

6 months to 3 years


(also more common in autumn)

What would encourage you to admit a child with croup?

- If moderate or severe (e.g. prominent inspiratory stridor at rest)
- If <6 months of age


- Known airway abnormality (e.g. Down's, Laryngomalacia)


- Uncertainty about diagnosis (important differentials incl. epiglottitis, peri-tonsillar abcess, tracheitis, inhaled foreign body)

Emergency treatment of croup?

High-flow oxygen




Nebulised adrenaline

"Croup is most common in those under 6 months"


True or false?

False!


Commonest between 6 months and 3 years.

A 16-month-old girl is reviewed by her GP. She has a 3 day history of fever and coryzal symptoms. Overnight she has developed a harsh cough. On examination she has a temperature of 38ºC and inspiratory stridor is noticed although there are no signs of intercostal recession. What is the most likely diagnosis?

Croup

10 month old boy with 3/7 coryza and fever. Feeding well. Temp 37.6C, RR 36 and no intercostal recession. Mild expiratory wheeze bilaterally with the odd fine crackle. Most appropriate management?


1.) Admit to hospital.


2.) Paracetamol + review


3.) Amoxicillin + CXR + review


4.) Bronchodilator via spacer + review


5.) Bronchodilator via spacer + prednisolone +review

Paracetamol and review.


This child likely has bronchiolitis. Guidelines do not support use of brochodilators in bronchiolitis.


No worrying signs indicating need for hospital admission (e.g. poor feeding (<50% of normal), grunting, O2 sats <94%)

Management of asthma under 5 years of age. Fill in the gaps:
 50-100 mcg/day beclometasone dipropionate
100-200 mcg/day beclometasone dipropionate
200-400 mcg/day beclometasone dipropionate
Leukotriene receptor antagonist
Long-acting beta2-agoni...

Management of asthma under 5 years of age. Fill in the gaps:


50-100 mcg/day beclometasone dipropionate


100-200 mcg/day beclometasone dipropionate


200-400 mcg/day beclometasone dipropionate


Leukotriene receptor antagonist


Long-acting beta2-agonist


Oral theophylline


Nebulised therapy


2 years


3 years


4 years

(1) = 200-400 mcg/day beclometasone dipropionate


(2) = Leukotriene receptor antagonist (e.g. Montelukast)


(3) = 2 years of age

Asthma guidelines for children aged under 5?

1.) As-required reliever therapy: short-acting beta2-agonist


2.) Regular preventer therapy: inhaled corticosteroids, 200-400mcg/day (if inhaled corticosteroids cannot be used, a leukotriene receptor antagonist)


3.) Children aged 2-5 years: trial of a leukotriene receptor antagonist. If already taking leukotriene receptor antagonist reconsider inhaled corticosteroids


Children aged under 2 years: refer to respiratory paediatrician


4.) Refer to a respiratory paediatrician

Asthma guidelines for children aged over 5?

1.) As-required reliever therapy: short-acting beta2-agonist


2.) Regular preventer therapy: inhaled corticosteroids, 200-400mcg/day*


3.) a. Add inhaled long-acting B2 agonist (LABA)


b. If good response to LABA, continue LABA; if benefit from LABA but control still inadequate -continue LABA + up inhaled steroid dose to 400 mcg/day*; no response to LABA - stop LABA and up inhaled steroid to 400 mcg/day.* If control still inadequate, trial leukotriene receptor antagonist or SR theophylline


4.) Increase inhaled corticosteroids to high-dose, up to 800mcg/day*


5.) Use daily steroid tablet at lowest dose providing control, Maintain inhaled corticosteroids at 800mcg/day, Refer to a paediatrician


*Beclometasone dipropionate or equivalent

A 9 year old boy has collapsed in the waiting room. 999 has been called. He does not respond to stimulation, there are no signs of respiration after 10 seconds, and no obvious foreign body in the mouth.


What is the most appropriate next step?

Give 5 rescue breaths