BODY TEMPERATURE Subnormal Normal Subfebrile Fever High fever Hyperpyrexia
ABG
<36.6°C 37.4°C 35.7 – 38.0°C 38.0°C >39.5°C >42.0°C
AGE
HR (bpm)
BP (mmHg)
Preterm Term 0-3 mo 3-6 mo 6-12 mo 1-3 yrs 3-6 yrs 6-12 yrs 12-17 yrs
120-170 120-160 100-150 90-120 80-120 70-110 65-110 60-95 55-85
55-75/35-45 65-85/45-55 65-85/45-55 70-90/50-65 80-100/55-65 90-105/55-70 95-110/60-75 100-120/60-75 110-135/65-85
pH: pCO2: pO2:
RR (cpm) 40-70 30-60 35-55 30-45 25-40 20-30 20-25 14-22 12-18
RBC
NB 4.8-7.1
Infant 3.8-5.5
WBC PMNs Lymph Hgb
9-30,000 61% 31% 14-24
6-17,500 61% 32% 11-20
Hct
44-64%
35-49
Platelets 140-300 200-423 Ret 2.6-6.5 0.5-3.1
22-26mEq/L +/- 2mEq/L 97%
Child 3.8-5.
Adole M: 4.6-6.2 F: 4.2-5.4 5-10,000 6-10,000 60% 60% 30% 30% 11-16 M: 14-18 F: 12-16 31-46 M: 40-54 F: 37-47 150-450 150-450 0-2 0-2
IDEAL BODY WEIGHT Age At Birth 3-12 mo 1-6 y 7-12 y
BT CT PTT
Caucasian <18.5 18.5 – 24.9 25 – 29.9
1-5 min 1-6 5-8 min 5-8 12-20sec 12-14
1-6 5-8 12-14
Kilograms 3kg (Fil) 3.35kg (Cau) Age (mo) + 9 / 2
Pounds 7 Age (mo) + 10 (F) Age (mo) + 11 (C) Age (y) x 5 + 17 Age (y) x 7 + 5
Age (y) x 2 + 8 Age (y) x 7 – 5 / 2
Given Birth Weight: Age Using Birth Weight in Grams < 6 mo Age (mo) x 600 + birth weight (gm) 6-12 mo Age (mo) x 500 + birth weight (gm) Expected Body Weight (EBW): Term Age in days – 10 x 20 + Birth Weight Pre-Term Age in days – 14 x 15 + Birth Weight
COUNT (%)
BMI Asian <18.5 18.5 – 22.9 ≥ 23.0 23 – 24.9 25 – 29.9 ≥ 30
HCO3: B.E.: O2 sat:
NORMAL LABORATORY VALUES
µ BP cuff should cover 2/3 of arm -: SMALL cuff: falsely high BP -: LARGE cuff: falsely low BP
Underweight Normal Overweight at risk Obese I Obese II
7.35-7.45 35-45 80-100
ANTHROPOMETRIC MEASUREMENTS
Age of Infant 4-5 months 1 year 2 years 3 years 5 years 7 years 10 years
1-6 5-8 12-14
Ideal Weight 2 x Birth Weight 3 x Birth Weight 4 x Birth Weight 5 x Birth Weight 6 x Birth Weight 7 x Birth Weight 10 x Birth Weight
30 – 39.9 >40
APGAR LENGTH / HEIGHT (50 cm) Age At Birth 1y 2-12 mo Age 0-3 mo 3-6 mo 6-9 mo 9-12 mo
Centimeters 50 75 Age x 6 + 77
Age Inches 20 30 Age x 2.5 + 30
At Birth 1y 6y
5-12 mo 1-2 yrs 3-5 yrs 6-20 yrs
Inches Transverse = AP Transverse > AP Transverse >>> AP
FONTANELS
st
Gain in 1 Year is ~ 25cm + 9 cm 3 cm per mo + 8 cm 2.67 per mo + 5 cm 1.6 cm per mo + 3 cm 1 cm per mo
Appropriate size at birth: Closes at: Anterior
Inches 35 cm (13.8 in) + 2 in (1/2 inches / mo) + 2 in (1/4 inches / mo) + 1 inch + 1.5 in (1/2 inches / year) + 1.5 in (1/2 inches / year)
2 x 2 cm (anterior) = 18 months, or as early as 9-12 months = 6 – 8 weeks or 2 – 4 months
TI =
+ 5.08cm (1.27cm / mo) + 5.08cm (0.635cm / mo) 2.54 cm + 3.81cm (1.27cm / mo) + 3.81cm (1.27cm / mo)
AGE Birth or 6 wks
DPT
6 wks
DOSE 0.05mL (NB) 0.1mL (older) 0.5mL
OPV HEPA B
6 wks 6 wks
2 drops 0.5mL
3 3
PO IM
MEASLES
9 mos
0.5mL
1
SC
BCG-2
School entry
0.1mL
1
ID
TetToxoid
Childbearing women
0.5mL
3
IM
(-) Response
Grimaces
A
(-) Movement
Some flexion / extension
R
Absent
Slow / Irregular
P
transverse chest diameter AP diameter
Function Eye Opening
Birth 1 year 6 years
Verbal
Infants/Young 4- Spontaneous 3- To speech 2- To pain 1- None 5- Appropriate 4- Inconsolable 3- Irritable 2- Moans 1- None 6- Spontaneous 5- Localize pain 4- Withdraw 3- Flexion 2- Extension 1- None
: 1.0 : 1.25 : 1.35
# 1
ROUTE ID
SITE RDeltoid
3
IM
Upper Outer thigh Mouth Anterolateral thigh Outer upper arm LDeltoid Deltoid
2 Completely pink > 100 Coughs, Sneezes, Cries Active movement Good, strong cry
GCS
Motor
EXPANDED PROGRAM ON IMMUNIZATION VACCINE BCG-1
G
Normal Mild / Moderate Asphyxia Severe asphyxia
THORACIC INDEX
Centimeters
1 Pink body/ Blue extremities Slow (<100)
A
8 – 10: 4 – 7: 0 – 3:
Posterior
HEAD CIRCUMFERENCE (33-38 cms) Age At Birth < 4 mo
Transverse-AP Diameter ratio 1.0 1.25 1.35
0 Blue / Pale Absent
Older Spontaneous To speech To pain None Oriented Confused Inappropriate Incomprehensible None Spontaneous Localize pain Withdraw Flexion Extension None
ADVERSE REACTIONS FROM VACCINES INTERVAL
BCG
DPT
4 wks 4 wks 4 wks
1 mo then 6-12 mos
OPV HEPA B MEASLES
1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks 2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis 1. Fever, local soreness 2. Convulsions, encephalitis / encephalopathy, permanent brain damage Paralytic Polio Local soreness 1. Fever & mild rash 2. Convulsions, encephalitis / encephalopathy, SSPE, death ACTIVE BCG DPT OPV Hep B Measles Hib MMR Tetanus Toxoid Varicella
PASSIVE Diphtheria Tetanus Tetanus Ig Measles Ig Rabies (HRIg) Hep A Ig Hep B ig Rubella Ig
H.E.A.D.S.S.S. Sexual activities ◦ Sexual orientation? ◦ GF/BF? Typical date? ◦ Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs? Suicide/Depression ◦ Ever sad/tearful/unmotivated/hopeless? ◦ Thought of hurting self/others? ◦ Suicide plans? Safety ◦ Use seatbelts/helmets? ◦ Enter into high risk situations? ◦ Member of frat/sorority/orgs? ◦ Firearm at home? F.R.I.C.H.M.O.N.D. ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
Fluids Respiration Infection Cardiac Hematologic Metabolic Output & Input [cc/kg/h] N: 1-2 Neuro Diet
H.E.A.D.S.S.S. Home Environment ◦ With whom does the adolescent live? ◦ Any recent changes in the living situation? ◦ How are things among siblings? ◦ Are parents employed? ◦ Are there things in the family he/she wants to change? Employment and Education ◦ Currently at school? Favorite subjects? ◦ Patient performing academically? ◦ Have been truant / expelled from school? ◦ Problems with classmates/teachers? ◦ Currently employed? ◦ Future education/employment goals? Activities ◦ What he/she does in spare time? ◦ Patient does for fun? ◦ Whom does patient spend spare time? ◦ Hobbies, interests, close friends? Drugs ◦ Used tobacco/alcohol/steroids? ◦ Illicit drugs? Frequency? Amount? Affected daily activities? ◦ Still using? Friends using/selling?
NUTRITION AGE 0-5 mo 8-11 mo 1-2 y 3-6 y 7-9 y 10-12 y 13-15 y 16-19 y
WT. 3-6 7-9 10-12 14-18 22-24 28-32 36-44 48-55
TCR β TCR
CAL 115 110 110 90-100 80-90 70-80 55-65 45-50
CHON 3.5 3.0 2.5 2.0 1.5 1.5 1.5 1.2
= Wt at p50 x calories = CHON X ABW
Total Caloric Intake
: calories X amount of intake (oz)
Gastric Capacity
: age in months + 2
Gastric Emptying Time
: 2-3 hours
1:1 Alacta Enfalac Lactogen Lactum Nan Nestogen Nutraminogen Pelargon Prosobee
1:2 Bonna Nursoy Promil S-26 Similac SMA
THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE by Stephen R. Covey
Habit 1: Habit 2: Habit 3: Habit 4: Habit 5:
Be Proactive Begin with the end in mind Put First Things First Think Win-Win Seek first to understand and then to be understood Habit 6: Synergize Habit 7: Sharpen the saw
EXPECTED LA SALLIAN GRADUATE ATTRIBUTES (ELGA) 1. Competent & safe physicians 2. Ethical & socially responsible Doctors / practitioners 3. Reflective lifelong learners 4. Effective communicators 5. Efficient & innovative managers
DIARRHEA
ACUTE DIARRHEA (at least 3x BM in 24 hrs)
◦ ◦
Chronic : >14 days, non-infectious causes Persistent : >14 days, infectious cause
◦
ORS vol. after each loose stool 1 day <24 mo 2-10 y.o. >10 y.o.
5-100mL 100-200mL As much as wanted
500mL 1000mL 2000mL
4 Major Mechanisms 1. Poorly absorbed osmotically active substances in lumen 2. Intestinal ion secretion (increased) or decreased absorption 3. Outpouring into the lumen of blood, mucus 4. Derangement of intestinal motility Rotaviral AGE (vomiting first then diarrhea)
For severe dehydration / WHO hydration (fluid: PLR 100cc/kg) Age <12 >12
30mL/kg 1H 30 mins
75mL/kg 5H 2½H
Ingestion of rotavirus ► rotavirus in intestinal villi ►destruction of villi (secretory diarrhea ▼absorption ▲ secretion) ► AGE Assessment of dehydration (Skin Pinch Test)
Patient in SHOCK ◦ ◦ ◦
20-30cc/kg IV fast drip but in infants 10cc/kg IV (repeat if not stable) If responsive & stable 75/kg x 4-6 hours
◦ ◦
(+) if > 2 seconds no dehydration if skin tenting goes back immediately
ETIOLOGY of AGE Bacteria Aeromonas Bacillus cereus Campylobacter jejuni Clostridium perfringens Clostridium difficile Escherichia coli Plesiomonas shigelbides Salmonella Shigella Staphylococcus aureus Vibrio cholerae 01 & 0139 Vibrio parahaemolyticus Yersinia enterocolitica
Viruses Astroviruses Caloviruses Norovirus Enteric Adenovirus Rotavirus Cytomegalovirus Herpes simplex virus
Parasites Balantidium coli Blastocyctis hominis Cryptosporidium Giardia lamblia Amoeba Ascariasis Cholera Shigella Salmonella
TREATMENT PLAN A
Metronidazole Al/mebendazole Tetracyline TMP/SMX (Cotri) Chloramphenicol
TREATMENT PLAN C
4 Rules of Home Treatment
Treat severe dehydration QUICKLY!
1. Give extra fluid (as much as the child will take)
1. Start IV fluid immediately 2. If the child can drink, give ORS by mouth while the IV drip is being set up 3. Give 100mL/kg Lactated Ringer’s solution
> Breastfeed frequently & longer at each feeding > if the child is exclusively breastfed, give one or more of the following in addition to breastmilk ◦ ORS solution ◦ food based fluid (e.g. soup, rice, water) clean water
Infants (<12mo) Children (12mo-5yrs)
How much fluid to be given in addition to the usual fluid intake? Up to 2 years:
First give 30mL/kg in:
Age
50-100 mL after each loose stool
Then give 70mL/kg in:
1 hour*
5 hours
30 min*
2 ½ hours
Repeat once if radial pulse is very weak or not detectable
2 years or more: 140-200 mL :- give frequent small sips from a cup :- if the child vomits, wait for 10 min then resume :- continue giving extra fluids until diarrhea stops
◦
reassess the child every 15-30 min. if dehydration is not improving, give IV fluid more rapidly
◦
also give ORS (~5mL/kg/hr) as soon as the child can drink [usually after 3-4 hours in infants; 1-2 hours in children]
◦
reassess after 6 hrs (infant) & 3 hrs (child)
2. Give Zinc supplements Up to 6 mo: 1 half tab per day for 10-14 days 6 months or more: 1 tab or 20mg OD x 10-14 days 3. Continue feeding 4. Know when to return
TREATMENT PLAN B Recommended amount of ORS over 4 hour period Age up to: Wt: (mL) ◦ ◦
4 mo – 4 mo <6kg 200-400
12 mo – 12 mo 6-9.9kg 400-700
Use child’s age only when weight is not known Approximate amount of ORS (mL)
CHILDS WT (kg) x 25 ◦ ◦ ◦ ◦
if the child wants more ORS than shown, give more give frequent small sips from a cup if the child vomits, wait for 10 min then resume continue breastfeeding whenever the child wants
AFTER 4 HOURS ◦ reassess the child & classify dehydration status ◦ select the appropriate plan to continue treatment ◦ begin feeding the child while at the clinic
2 yrs – 2 yrs 10-11.9kg 700-900
5 yrs 2-19kg 900-1400
Glucose: 100mmol/L Na: 60 mol/L K: 20 mmol/L
Cl: 50mmol/L Mg: 5mmol/L Citrate: 10 mmol/L
•
Glucose 45mEq Na: 20mEq K: 35mEq Citrate: 30mEq Dextrose: 20g
Gluconate: 5mmol/L
• •
Hydrite -: 2 tab in 200ml water or 10sachets in 1L water Glucose: 111mmol/L Na: 90 mmol/L K: 20 mmol/L
Cl: 80mmol/L HCO3: 5mmol/L
Pedialyte 45 0r 90 -: prevention of DHN & to maintain normal fluidelectrolyte balance in mild to moderate dehydration. Glucose 90mEq Na: 20mEq K: 80mEq Citrate: 30mEq Dextrose: 25g
Pedialyte mild 30 -: to supplement fluid & electrolyte loss due to active play, prolonged exposure, hot and humid environment
Glucose: 11mml/L Na: 90 mmol/L K: 20 mmol/L
Glucose: 30mEq Na: 20mEq K: 30mEq
Mg: 4mEq lactate: 20mEq Ca: 4mEq Energy: 20kcal/ 100ml
Glucolyte 60 -: for acute DHN secondary to GE or other forms of diarrhea except CHOLERA. In burns, postsurgery replacement or maintenance, mild-salt loosing syndrome, heat cramps and heat exhaustion in adults.
IV-FLUID COMPOSITIONS (Commonly Used for Infants and Child):
ORS •
Bacterial - Streptococcus pneumoniae - Group B streptococci (neonates) - Group A streptococci - Mycoplasma pnemoniae (adolescents) - Chlamydia trachomatis (infants) - Mixed anearobes (aspiration pneumonia) - Gram negative enteric (nosocomial pneumonia) Viral - Respiratory syncitial virus - Parainfluenza type 1-3 - Influenza types A, B - Adenovirus - Metapneumovirus Fungal - Histoplasma capsulatum - Cryptococcus neoformans - Aspergillus sp. - Mucormycosis - Coccidioides immitis - Blastomyces dermatitides - Pneumocystis carinii
Young Infants < 2months old
ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)
ETIOLOGY OF PNEUMONIA
Child Age 2months up to 5years
(Croup)
(bird, bat contact) (bird contact) (immunosuppressed) (immunosuppressed) (immunosuppressed, HIV, steroids)
SMR GIRLS LUDAN’S METHOD (HYDRATION THERAPY)
< 15 kg, < 2 y/o > 15 kg, 2 y/o
MILD DEHYDRATION 50 cc/kg 30 cc/kg D5 0.3% in 6-8 hours
MODERATE DEHYRATION 100 cc/kg 60 cc/kg st 1 hr: ¼ Plain LR Next 5-7 hrs: ¾ D5 0.3% in 5-7 hours
SEVERE DEHYDRATION 150 cc/kg 90 cc/kg st 1 hr: ⅓ Plain LR Next 5-7 hrs: ⅔ D5 0.3% in 5-7 hours
HOLIDAY-SEGAR METHOD (MAINTENANCE) WEIGHT 0 - 10 kg 11- 20 kg > 20 kg NOTE:
TOTAL FLUID REQUIREMENT 100 mL / kg 1000 + [ 50 for each kg in excess of 10 kg] 1500 + [ 20 for each kg in excess of 20 kg]
Computed Value is in mL/day Ex. 25kg child Answer: 1500 + [100] = 1600cc/day
Stage 1 2 3 4 5
Pubic Hair Preadolescent Sparse, lightly pigmented, straight, medial border of labia
Breasts Preadolescent Breast & papilla elevated, as small mound, areola diameter increased Breast & areola enlarged, no contour separation Areola & papilla formed secondary mound Mature, nipple projects, areola part of general breast contour
Darker, beginning to curl, ▲amount Course, curly, abundant but amount < adult Adult, feminine triangle, spread to medial surface of thigh
SMR BOYS Stage 1 2 3 4 5
Pubic Hair None Scanty, long slightly pigmented Darker, starts to curl, small amount Resembles adult type but less in quantity, course, curly Adult distribution, spread to medial surface of thigh
Penis Preadolescent Slightly enlargement
Testes Preadolescent Enlarged scrotum, pink texture altered
Longer
Larger
Larger, glans & breadth ▲ in size
Larger, scrotum dark
Adult size
Adult size
ATYPICAL PNEUMONIA -: -: -: -: -:
> 3-12 mo - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus
extrpulmonary manifestations low grade fever patchy diffuse infiltrates poor response to Penicillin negative sputum gram stain Etiologic Agents Grouped by Age
> Neonates (<1mo) - GBS - E. coli - other gram (-) bacilli - Streptococcus pneumoniae - Haemophilus influenza (Type B) > 1-3 months * Febrile pneumonia - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenza (Type B) * Afebrile pneumonia - Chlamydia trachomatis - Mycoplasma homilis - CMV
DENGUE > MOT:
mosquito bite
> Vector:
Aedes aegypti
> 2-5 yrs - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus > 2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus
Dengue Fever Syndrome (DFS) (man as reservior)
> Factors affecting transmission: - breeding sites, high human population density, mobile viremic human beings
Biphasic fever (2-7 days) with 2 or more of the ff: 1. headache 2. myalgia or arthralgia 3. retroorbital pain 4. hemorrhagic manifestations [petechiae, purpura, (+) torniquet test] 5. leukopenia
DENGUE PATHOPHYSIOLOGY
Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse 2. narrow pulse pressure (<20mmHg) 3. hypotension for age 4. cold, clammy skin & irritability / restlessness DANGER SIGNS OF DHF
> Age incidence peaks at 4-6 yrs > Incubation period:
4-6 days
> Serotypes: - Type 2 – most common - Types 1& 3 - Type 4– least common but most severe > Main pathophysiologic changes: a. increase in vascular permeability ▼ extravasation of plasma - hemoconcentration rd - 3 spacing of fluids b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy
MANAGEMENT OF DENGUE A. Vital Signs and Laboratory Monitoring Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)
Dengue Hemorrhagic Fever (DHF) 1. fever, persistently high grade (2-7 days) 2. hemorrhagic manifestations - (+) torniquet test - petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis 3 3. Thrombocytopenia (< 100,000/mm ) 4. Hemoconcentration - hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following volume replacement - signs of plasma leakage [pleural effusion, ascites, hypoproteinemia]
1. abdominal pain (intense & sustained) 2. persistent vomiting 3. abrupt change from fever to hypothermia with sweating 4. restlessness or somnolence Grading of Dengue Hemorrhagic Fever
MANAGEMENT OF HEMORRHAGE
Torniquet Test:
SBP + DBP = mean BP for 5 mins. 2
if ≥20 petechial rash per sq. inch on antecubital fossa (+) test Herman’s Rash: - usually appears after fever lysed - initially appears on the lower extremities - not a common finding among dengue patients - “an island of white in an ocean of red” Recommended Guidelines for Transfusion: Transfuse: - PC < 100,000 with signs of bleeding - PC < 20,000 even if asymptomatic - use FFP if without overt bleeding - FWB in cases with overt bleeding or signs of hypovolemia
URINARY TRACT INFECTION Suggestive UTI: 3 - Pyuria: WBC ≥ 5/HPF or 10mm - Absence of pyuria doesn’t rule out UTI - Pyuria can be present w/o UTI Presumptive UTI: - (-) urine culture - lower colony counts may be due to: * overhydration * recent bladder emptying * previous antibiotic intake Proven or Confirmed UTI: - (+) urine culture ≥ 100,000 cfu/mL urine of a single organism - multiple organisms in culture may indicate a contaminated sample
> if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate st
3-7cc/kg/hr depending on the Hct (1 no.) level (D5LR) 10-20cc/kg fast drip PLR - hypotension, narrow pulse pressure fair pulse Leukopenia in dengue: therefore:
probable etiology is Pseudomonas
give Meropenem or Ceftazidime
ACUTE GLOMERULONEPHRITIS Complications of AGN - CHF 2° to fluid overload - HPN encephalopathy - ARF due to ê GFR
RHEUMATIC FEVER
TREATMENT OF RHEUMATIC FEVER
JONES CRITERIA:
STAGES of AGN - Oliguric phase [7-10days] – complications sets in - Diuretic phase [7-10days] – recovery starts - Convalescent phase [7-10days] – patients are usually sent home Prognosis - Gross hematuria - Proteinuria - ▼C3 - microscopic hematuria
2-3 weeks 3-6 weeks 8-12 weeks 6-12 mo or 1-2 years 4-6 weeks
- HPN
A. Major Manifestations - Carditis - Polyarthritis - Chorea - Erythema Marginatum - Subcutaneous Nodules
A. Antibiotic Therapy - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin (50-60%) (70%) (15-20%) (3%) (1%)
B. Minor Manifestations - Arthralgia - Fever - Laboratory Findings of: ▲ Acute Phase Reactants (ESR / CRP) Prolonged PR interval C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection - (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test
*** NOTE:
Sumapen
= Oral Penicillin!
B. Anti-Inflammatory Therapy 1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks 2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days
PREVENTON A. Primary Prevention
+
> Hyperkalemia may be seen due to Na retention ++ > Ca decreases in PSAGN > ▲ in ASO titer - normal within 2 weeks - peaks after 2 weeks - more pronounced in pharyngeal infection than in cutaneous
B. Secondary Prevention
C. Duration of Chemoprophylaxis
- 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin
KAWASAKI DISEASE TREATMENT CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT)
Currently Recommended Protocol: A. IV-Immunoglobulin
A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation “High Grade Fever of at least 5 days” DOES NOT Respond to any kind of Antibiotic!
2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation as measured by days of Fever, ESR, CRP, Platelet Count, Hgb, and Albumin
B) Presence of 4 of the 5 Criteria 1. Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%) 2. Changes of the Lips and Oral Cavity (At least ONE) 3. Changes of the Extremities (At least ONE) 4. Polymorphous Exanthem (92%) 5. Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%)
NOTE:
> Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons > Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause > Status epilepticus:
>30min or back-to-back w/o return to baseline
There is a TIME FRAME of 10 days
B. Aspirin HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG THEN Reduced to Low Dose Aspirin (3-5mg/kg/day) AND Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease)
HARADA Criteria - used to determine whether IVIg should be given - assessed within 9 days from onset of illness 1. WBC > 12,000 2. PC <350,000 3. CRP > 3+ 4. Hct <35% 5. Albumin <3.5 g/dL 6. Age 12 months 7. Gender: male • •
SEIZURES
> Etiology: - V ascular - I nfections - T raumatic - A utoimmune - M etabolic - I diopathic - N eoplastic - S tructural
: : : : : : : :
- S yndrome
:
AVM, stroke, hemorrhage meningitis, encephalitis SLE, vasculitis, ADEM electrolyte imbalance “idiopathic epilepsy” space occupying lesion cortical malformation, prior stroke genetic disorder
IVIg is given if ≥ 4 of 7 are fulfilled If < 4 with continuing acute symptoms, risk score must be reassessed daily
TYPES OF SEIZURES
CLASSIFICATION BY CAUSE
A. Partial Seizures (Focal / Local) – Simple Partial – Complex Partial (Partial Seizure + Impaired Consciousness) – Partial Seizures evolving to Tonic-Clonic Convulsion
A. Acute Symptomatic (shortly after an acute insult) – Infection – Hypoglycemia, low sodium, low calcium – Head trauma – Toxic ingestion
B. Generalized Seizures – Absence (Petit mal) – Myoclonic – Clonic – Tonic – Tonic-Clonic – Atonic
B. Remote Symptomatic – Pre-existing brain abnormality or insult – Brain injury (head trauma, low oxygen) – Meningitis – Stroke – Tumor – Developmental brain abnormality C. Idiopathic – No history of preceding insult – Likely “genetic” component
SIMPLE FEBRILE SEIZURE vs. COMPLEX FEBRILE SEIZURE Febrile Seizure: “A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”
BRONCHIAL ASTHMA (GINA GUIDELINES) Day symptoms Limitation of activities Nocturnal Sx (awakening) Need for reliever Lung function Exacerbation
Controlled
Partly Controlled
none
> 2x per wk
none
any
none
any
< 2x per wk
> 2x per wk
normal
< 80%
none
> 1x per yr
Uncontrolled
3 or more symptoms of Partly Controlled Asthma in any week
1x / week
SIMPLE FEBRILE SEIZURE A. Criteria for an SFS – < 15 minutes – Generalized-tonic-clonic – Fever > 100.4 rectal to 101 F (38 to 38.4 C) – No recurrence in 24 hours – No post-ictal neuro abnormalities (e.g. Todd’s paresis) – Most common 6 months to 5 years – Normal development – No CNS infection or prior afebrile seizures B. Risk Factors st nd – Febrile seizure in 1 / 2 degree relative – Neonatal nursery stay of >30 days – Developmental delay – Height of temperature C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy) – Developmental delay – Complex FS (possibly > 1 complex feature) – 5% > 30 mins => _ of all childhood status – Family History of Epilepsy – Duration of fever
Clinical Features: TUBERCULOSIS A. Pulmonary TB – fully susceptible M. tuberculosis, – no history of previous anti-TB drugs – low local persistence of primary resistance to Isoniazid (H) ☤
2HRZ OD then 4HR OD or 3x/wk DOT
– Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary) – previous anti-TB use – close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H. – ☤ 2HRZ + E/S OD, then 4 HR + E/S OD or 3x/week DOT B. Extrapulmonary TB – Same in PTB – For severe life threatening disease (e.g. miliary, meningitis, bone, etc) ☤
2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT
RESPIRATORY DISTRESS SYNDROME (Hyaline Membrane Disease)
1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting 2. Pallor – from anemia, peripheral vasoconstriction 3. Onset – within 6 hours of life Peak severity – 2-3 days Recovery – 72 hours
o Male, preterm, low BW, maternal DM, & perinatal asphyxia o Corticosteroids: • most successful method to induce fetal lung maturation • Administered 24-48 hours before delivery decrease incidence of RDS • Most effective before 34 weeks AOG
Retractions: o Due to (-) intrapleural pressure produced by interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall
o Microscopically: diffuse atelectasis, eosinophilic membrane
Nasal flaring: o Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance
Pathophysiology: 1. Impaired/delayed surfactant synthesis & secretion 2. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance 3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis 5. Pulmonary vasoconstriction 6. Impaired endothelial &epithelial integrity 7. Proteinous exudates 8. RDS
Grunting: o Expiration through partially closed vocal cords • Initial expiration: glottis closedà lungs w/ gasà inc. transpulmo P w/o airflow • Last part of expiration: gas expelled against partially closed cords Cyanosis: o Central
– tongue & mnucosa (imp. Indicator of impaired gas exchange); depends on total amount of desaturated Hgb
UMBILICAL CATHERIZATION
NEWBORN RESUSCITATION µ AIRWAY: open & clear • Positioning • Suctioning • Endotracheal intubation (if necessary) µ BREATHING is spontaneous or assisted • Tactile stimulation (drying, rubbing) • Positive-pressure ventilation µ CIRCULATION of oxygenated blood is adequate • Chest compressions • Medication and volume expansion
RESUSCITAION MEDICATIONS Atropine Bicarbonate Calcium Calcium chloride Calcium gluconate Dextrose Epinephrine
0.02 ml/k IM, IV, ET 1-2 meq/k 10 mg elem Ca/k slow IV 0.33/k (27 mg Ca/cc) 1 cc/k (9 mg Ca/cc) 1g/k = 2 cc/k D50 4 cc/k D25 0.01 cc/k IV, ET
Cathether length • Standardize Graph – Perpedicular line from the tip of the shoulder to the umbilicus • Measure length from Xiphoid to umbilicus and add 0.5 to 1cm. • Birth weight regression formula – Low line : UA catheter in cm = BW + 7 – High line : UA catheter = [3xBW] + 9 – UV catheter length = [0.5xhigh line] + 1
Indications • Vascular access (UV) • Blood Pressure (UA) and blood gas monitoring in critically ill infants Complications • Infection • Bleeding • Hemorrhage • Perforation of vessel • Thrombosis w/ distal embolization • Ischemia or infarction of lower extremities, bowel or kidney • Arrhythmia • Air embolus
Procedure • Determine the length of the catheter • Restrain infant and prep the area using sterile technique • Flush catheter with sterile saline solution • Place umbilical tape around the cord. Cut cord about 1.5-2cm from the skin. • Identify the blood vessels. (1thin=vein, 2thick=artery) • Grasp the catheter 1cm from the tip. Insert into the vein, aiming toward the feet. • Secure the catheter • Observe for possible complications
Cautions • Never for: – Omphalitis – Peritonitis • Contraindicated in – NEC – Intestinal hypoperfusion Line Placement • Arterial line • Low line – Tip lie above the bifurcation between L3 & L5 • High line – Tip is above the diaphram between T6 & T9
BILIRUBIN PRETERM: 0-1 hr 1-2 d 3-5 d
mg/dl 1-6 6-8 10-12
mmol/L 17-100 100-140 170-200
mg/dl 2-6 6-7 4-12 <1
mmol/L 34-100 100-120 70-200 <17
TERM 0-1 hr 1-2 d 3-5 d 1 mo
KRAMERS CLASSIFICATION OF JAUNDICE ZONE
JAUNDICE
I
Head & neck Upper trunk to umbilicus Lower trunk to thigh Arms, legs, below Hands & feet
II III IV V
SERUM BILIRUBIN 6-8 9-12 12-16 15 15
MKD COMPUTATION LUMBAR PUNCTURE •
•
the technique of using a needle to withdraw cerebrospinal fluid (CSF) from the spinal canal.
SPINE • spinal cord stops near L2 • lower lumbar spine (usually between L3-L4 or L4–5) is preferable
To diagnose other medical conditions such as: – viral and bacterial meningitis – syphilis, a sexually transmitted disease – bleeding around the brain and spinal cord – multiple sclerosis, (affects the myelin coating of the nerve fibers of the brain and spinal cord) – Guillain-Barré syndrome, (inflammation of the nerves)
Wt x mkd x preparation [mg/mL] = mL per dose e.g.
5ml = 5mL per dose 120mg
Dose x preparation x frequency = mkd weight µ Paracetamol Drops = Wt: move 1 decimal point to the left Age Wt 1 10 kg 2 12 3 14 4 16 5 18 6 20
Caution & Contraindications • Increased ICP • Bleeding diasthesis • Traumatic Tap • Overlying skin infection • Unstable patient
Indication • to diagnose some malignancies (brain cancer and leukemia) • to assess patients with certain psychiatric symptoms and conditions. • for injecting chemotherapy directly into the CSF (intrathecal therapy)
x
* If per day, divide total (mL) by the # of divided doses
Complication • Local pain • Infection • Bleeding • Spinal fluid leak • Hematoma (spinal subdural hematoma • Spinal headache • Acquired epidermal spinal cord tumor
CSF • clear, watery liquid that protects the central nervous system from injury • cushions the brain from the surrounding bone. • It contains: – glucose (sugar) – protein – white blood cells • Rate : 500ml/day or 0.35ml/min • Range : 0.3-04 ml/min • Volume : 50ml (infants) 150ml (adults)
12kg x 10mg
1 drop 1 teaspoonful 1 tablespoonful 1 wineglassful 1 glassful 1 grain 1 pint 1 quart 1 ounce 1 Kg 1 lb
= 1/20 mL = 5 mL = 15 mL = 60 mL = 2 ounces = 250 mL = 8 ounces = 60 mg = 500 mL = 1000 mL = 30 mL = 2.2 lbs = 0.45359 Kg
Empirical dose Ø 6 months ¼ tsp TID QID Ø 6 mos – 2 yrs ½ tsp Ø 2-6 1 tsp Ø 6-9 1 ½ tsp Ø 9-12 2 tsp
Procedure • Apply local anesthetic cream (ideally) • Position the patient • Prepare the skin using sterile techniques • Anesthetize the area with lidocane • Puncture the skin in the midline just caudal to the spinus process, angle cephalad toward the umbilicus using a g23 needle • Collect the CSF for analysis CSF Analysis 1. Gram stain, culture and sensitivity 2. Cell count, differential count 3. Chemistries – sugar, protein 4. Special studies After care • Cover the puncture site with a sterile bandage, apply pressure packing. • Patients must remain lying down for 4-6 hours • NPO for 4 hrs
CLINICAL FEATURES CLASSIFICATION BASED ON SEVERITY MILD INTERMITTENT Exacerbation
Brief
Day-time Sxs Nightime Sxs PEFR PEFR VAR FEV1
<1x/wk <2x/mo >80% <20% >80%
MILD Affects daily activity & sleep >1x/wk >2x/mo >80% 20 - 30% >80%
PERSISTENT MODERATE Affects daily activity & sleep daily >1x/wk 60 - <80% >30% 60 - <80%
SEVERE Limits daily activity & sleep continuous frequent <60% >30% <60%
Breathless
Talks in Alertness RR Accessory muscles & retractions
MODERATE
sentences may be agitated
- talking - INF: softer, shorter, cry, difficulty feeding - prefers sitting phrases usually agitated
▲
▲
- walking - can lie down
none
(+)
SEVERE - at rest - INF: stops feeding - hunched forward words usually agitated often >30 mins (+)
RESPIRATORY ARREST
Imminent
drowsy / confused bradypnea (+) thoracoabd movement
