Amino acid Epinephrine Neonate
Empiric dose: 2-3g/day Preparation: 8%/100ml *
Asystole and Bradycardia 0.01 – 0.03 mkdose 1:10,000
Calcium
0.1 – 0.3 ml/kg/dose IV/ET
Empiric dose: 200-400/day Preparation: 100mg/ml
Infants and Children
* Wt x ED = mg/d x prep 1ml/100mg
1st dose: 0.01 mg/kg 1:10,000 0.1 ml/kg max dose: 1 mg (10ml) ET Uncuffed in patients ≤ 8 y/o Age in years + 4 (uncuffed) 4 + 3 (cuffed)
Sodium Empiric dose: Preparation: 2.5 meqs/mL * Wt x ED 2.5 Potassium
16 + age/4
Empiric dose:
Depth: 3x FT size
Preparation: 2 meqs/mL * Wt x ED 2
Dopamine IVRF x (dopa) x 60 800 or 400 800 – 1 cc dopa + 49cc D5W 400 – 0.5 cc dopa + 49 cc D5W Blood component Replacement Volume of PRBC’s = EBV (ml) x DHCT – Actual HCT of PRBC’s (0.55) Estimated Blood Volume Age Total Blood Volume (ml/kg) Preterm 90-105 Term 78-86 1-12 mos 73-78 1-3 years 74-82 4-6 years 80-86 7-18 year 83-90 TPN Compute for electrolytes first (Na, K, Ca, AA) AA of milk – 10.48 x volume of feeding 1000 AA of milk – AA required = AA TPN
Feeding
BW <750 g
TPR of Newborns 1-2 days 3-4 days 100-250 150-300
7-30 days 120-180
750-1000g
80-150
100-150
120-180
1000-1500g
60-100
80-150 80-150
120-180
>1500g
60-80
100-150
120-180
CPAP CA = 100 – F102 x CPAP 79 O2 = CPAP – CA
WHO Treatment Plan for Dehydration Dehydration Plan A ORS <24 months 50-100ml 500ml/day 2-10 years 100-200ml 1000ml/day 10 years or more As tolerated 2000ml/day Plan B Moderate or Some Dehydration ORS to be given in the 1 st 4 hours * 75ml/kg BW Plan C Severe Dehydration: IV 100ml/kg PLRS or PNSS <12 mos older 30ml/kg 1 hr 30 mins
Breastmilk: 20 cal/30ml or 1 oz.
70ml/kg
Formula: 24 cal/3oml or 1 oz.
Anion Gap [Na] – ([HCO3] + [Cl]) Normal: 12 meqs/L (range: 8-16meqs/L) Increased Anion Gap DKA Renal Failure Lactic acidosis Hyperglycemic Nonketotic Coma Disorders of AA metabolism Large amount of Penicillin Salicylate poisoning Ethylene glycol/methanol ingestion Decreased Anion Gap Nephrotic syndrome Lithium ingestion Multiple myeloma
Total Caloric Input Amount of feeding x Frequency x Cal 30cc = Present weight
Dextrosity K = Desired Dx – Actual Actual Dx or Total of electrolytes x Dx/45 D50 – Actual K x TFR x weight = Amount of D5050
GIR Dextrosity x desired rate x K (0.167) Weight Normal: 4-8 mg/kg/min
Total Fluid Requirement Amount of feeding x frequency Present weight
5 hours
2 1/2hours
PEFR in 6-7 y/o MALES FEMALES
( Height in cm – 100 ) 5+ 175 ( Height In cm – 100 ) 5+ 170
Peak flow variability = Highest Reading - Lowest reading x 100 Highest reading
IMMUNIZATIONS BCG
VITAL SIGNS AT VARIOUS AGE
Intradermal < 12 months: 0.05 ml > 12 months: 0.1 ml HBV Intramuscular 1st dose: at birth (within 24 hours): 0.5ml 2nd dose: 1 month 3rd dose: 6 months 4th dose: 3rd dose given < 6 months; No birth dose given ; Preterms, < 2 kg Measles Vaccine Subcutaneous 9 months but can be given as early as 6 months MMR 12 months Booster: 4-6 years old Given earlier: 4 weeks apart MMR + Varicella Subcutaneous 12-15 months Booster: 4-6 years old Provided that last dose is 3 months apart from last dose Influenza Intramuscular or Subcutaneous February – June 2 doses separated by 4 weeks HAV Intramuscular Recommended at 12 months 2nd dose: 6-12 months from 1 st dose Rotavirus Monovalent: oral, 2 doses, 3 weeks – 14 weeks (<15weeks), minimum interval: 4 week, not later than 24 weeks Pentavalent: oral 3 doses Typhoid Intramuscular History of travel Exposure to Salmonella typhi 2 years old, repeat every 2-3 years
APPEARS AT Birth Birth Birth Birth Birth 3 mos
Parachute
7-9 mos
Palmomental Shout/ pouting
BP
RR
Premature
12 0-170
55-75/ 35-45
40-70
0-3 mos
100-150
65-85/ 45-55
35-55
3-6 mos
90-120
70-90/ 50-65
30-45
6 weeks
Birth Birth Birth Birth Present in various neurologic conditions such as Down’s syndrome Infancy
5-6 mos 4-6 mos 4-6 mos
1 year
Length/ Height for AGE Above 3 Above 2 Above 1 Median Below -1 Below -2 Below -3
Very tall NORMAL
Weight for AGE Use weight for length, BMI for age chart
NORMAL
25-40
90-105/ 55-70
20-30
3-6 yr
65-110
95-110/ 60-75
20-25
6-12 yr
60-95
100-120/ 60-75
14-22
12 (*) yr
55-85
110-135/ 65-85
12-18
Infants 6-12 months old
Wt. in grams= (age in mos x 500) + BW
≥ 2 years old
Wt. in Kg= (age in year x 2) + 8
6 to 12 years old
Wt. in Kg= ((age in year x 7) – 5) / 2
MNEMONICS FOR HEIGHT 1 st year
Height in = 1.5 x birth length Height in 2 nd year= 30 inches or ½ of mature height (boys) Height in 3 rd year = 36 inches (3 ft) Height in 4 th year = 40 inches or 2 x birth length Height in 13th year = 3 x birth length Height in cm = (age in years x 5) + 80
RECOMMENDED ENERGY and NUTRIENT INTAKE PER DAY (RENI) From 0-18 years old Population Group Infants, mos Birth - <6 6- <12 Children, y 1-3 4-6 7-9 Males, y 10-12 13-15 16-18 19-29 30-49 50-64 65+ Females, y 10-12 13-15 1618
Weight (kg)
Energy (kcal)
Protein (g)
6 9
560 720
9 14
13 19 24
1070 1410 1600
28 38 43
34 50 58 59 59 59 59
2140 2800 2840 2490 2420 2170 1890
54 71 73 67 67 67 67
35 49 50
1920 2250 2050
49 63 59
CLASSIFICATION of SEX MATURITY STATES in GIRLS SMR STAGE
PUBIC HAIR
BREASTS
1
Preadolescent
Preadolescent
2
Sparse, lightly pigmented, straight, medial border of labia Darker, beginning to curl, increased amount Coarse, curly, abundant, but less than in adult Adult feminine triangle, spread to medial surface of thigh
Breast and papilla elevated as small mound; diameter of areola increased
3
5
Weight for BMI for Length/ Age Height OBESE OVERWEIGHT POSSIBLE RISK OF OVERWEIGHT
80-100/ 55-65
70-110
Wt. in grams= (age in mos x 600) + BW
4
Z-SCORES
80-120
1-3 yr
Infants < 6 months old
DISAPPEARS AT 3 mos 3 mos 4-6 mos 6-7 mos 2 years 12 mos Persists throughout life
Birth
6-12 mos
MNEMONICS FOR WEIGHT
PRIMITIVE REFLEXES REFLEX Suck Root Moro Tonic Neck Babinski Landau
Walking/ Stepping Palmar grasp Galant Swimming Babkin
HR
AGE
Breast and areola enlarged, no contour separation Areola and papilla form secondary mound Mature, nipple projects, areola part of general breast contour
CLASSIFICATION of SEX MATURITY STATES in BOYS SMR STAGE
PUBIC HAIR
BREASTS
1
None
Preadolescent
2
Scanty, long, slightly pigmented
Enlarge scrotum, pink, texture altered
3
Darker, starting to curl, small amount
Larger
Resembles adult type, but less quantity, coarse, curly Adult distribution, spread to medical surface of thigh
Larger, scrotum dark
STUNTED
Underweight
WASTED
4
Severely Stunted
Severely Underweigh t
SEVERELY WASTED
5
Adult size
Assessment of Dehydration According to the World Health Organization*
MODIFIED GLASGOW COMA SCALE FOR INTANTS AND CHILDREN Area Assessed Eye Opening
Verbal Response
Infants
Children
Score
Open spontaneously
Open spontaneously
4
Open in response to verbal stimuli Open in response to pain only No response
Open in response to verbal stimuli Open in response to pain only No response
Coos and babbles
Oriented, appropriate
5
Irritable cries Cries in response to pain
Confused
4
Inappropriate words
3
Severe Dehydration
Moans in response in pain Motor Response
Two of the following signs: -Lethargic or unconscious -Sunken eyes -Not able to drink or drinking poorly -Skin pinch goes back very slowly
No response Moves s pontaneously and purposefully Withdraws to touch Withdraws in response to pain Responds to pain with decorticate posturing (abnormal flexion) Responds to pain with decerebrate posturing (abnormal extension) No response
3 2
Some Dehydration
1
Incomprehensible words or nonspecific sound No response Obeys commands
Responds to pain with flexion
Responds to pain with extension No response
No Dehydration
DEHYDRATION MINIMAL OR NONE (<3% Loss of BW) Well; alert
MILD NTO MODERATE (3-9% Loss of BW)
SEVERE (>9% BW)
Normal, fatigued or restless, irritable
Apathetic, lethargic, unconscious
Drinks normally, might refuse liquids
Thirsty; eager to drink
Drinks poorly; unable to drink
Heart Rate
Normal
Normal to increased
Tachycardia with bradycardia in most severe cases
Quality of Pulse
Normal
Normal to decreased
2
Breathing
Normal
Normal; fast
Weak, thread, or impalpable Deep
1
Eyes Tears
Normal Present
Slightly sunken Decreased
Deeply sunken Absent
Moist
Dry
Parched
2
SYMPTOMS
1 6
Localizes painful stimuli Withdraws i n response to pain
Mental Status
5 Thirst
4
3
Mouth and Tongue Skinfold
GLASGOW COMA SCALE FOR <5 years old BEST MOTOR RESPONSE (6) Spontaneous Localizes Normal Flexion Abnormal Flexion Abnormal Extension Flaccid VERBALIZATION (5) Appropriate for age, fixes and follows, social smile Cries but consolable Persistently irritable Restless/Lethargic None EYE OPENING (4) Spontaneous To voice To pain Not at all MILD
Two of the following signs: -Restless, irritable -Sunken eyes -Thirsty, drinks eagerly -Skin pinch goes back slowly Not enough of the above signs to classify as some or severe dehydration
Capillary refill 6 5 4 3 2 1
Extremities Urine Output
5 4 3 2 1 4 3 2 1 14-15
MODERATE
9-13
SEVERE
3-8
Instant recoil
< 2 secs
>2 secs
Normal
Prolonged
Prolonged, minimal
Warm
Cool
Cool; mottled, cyanotic
Normal to decreased
Decreased
Minimal
CLINICAL CORRELATES OF DEHYDRATION Severity
Fluid Deficit in ml/kg Infants Adolescents
MILD
30 (3%)
Typically minimal findings but may have slightly dry, buccal mucus membranes, increased thirst, slightly decreased UO
50-60 (5-6%)
Dry buccal mucus membranes, tachycardia, little or no UO, lethargy, sunken eyes and fontanelles, loss of skin turgor
70-60 (7-6%)
Same as moderate plus a rapid thread pulse, no tears, cyanosis, rapid breathing, delayed capillary refill, hypotension, mottled skin, coma
50 (5%)
MODERATE
100 (10%)
KRAMER JAUNDICE SCALE Face Mid-abdomen Feet excluding soles and palms Including soles and palms Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
TSB ~ 5 mg/dl TSB ~ 15 mg/dl TSB ~ 20 mg/dl TSB ~ 25 mg/dl None Face and neck only Chest and back Abdomen below umbilicus to knees Arms and legs below knees Hands and feet
SEVERE
150 (15%)
SIGNS
HOLIDAY SEGAR METHOD 0-10 kg 10-20 kg
100ml/kg 50ml/kg
>20kg
20ml/kg
** total ml/kg divided by 24 hours < 10y/o or < 40kg: D5IMB > 10y/o or >40kg: D5NM
WHO TREATMENT PLAN for DEHYDRATION PLAN A ORS <24 months 50-100 ml 500 ml/day 2-10 years 100-200 ml 10000 ml/day 10 years or more As tolerated 2000 ml/day PLAN B Moderate or Some Dehydration ORS to be given in the 1 st 24 hours *75 ml/kg BW Plan C Severe Dehydration: IV 100 ml/kg PLRS or PNSS <12 mos older 30 ml/kg 1 hr 30 mins 70 ml/kg 5 hours 2 ½ hours
DEFICIT THERAPY (DT) MILD
MODERATE
SEVERE
<2 y/o or <15kg
5% Wt x 50
10% Wt x 100
15% Wt x 150
>2 y/o or > 15kg
3% Wt x 30
6% Wt x 60
9% Wt x 90
X1
X1.3
X1.5
** Run DT for 6 hours then re –assess
KAWASAKI DISEASE Diagnostic criteria: 1. Remittent fever (41C) persisting for more than 5 days 2. Bilateral conjunctival infection without exudates 3. Strawberry tongue, erythema and cracking of the lips 4. Erythema and edema od the hands and feet 5. Polymorphous exanthems 6. Unilateral CLAD > 1.5 CM Treatment: IVIG-treatment of choice -2 g/kg/day Aspirin 80-100 mg/kg/day Diagnosis: serial 2d echo aneurysm seen ACUTE STAGE •
SUSCEPTI BILITY
Fully Sensitive
Multidrug resistant
Intravenous immunoglobulin 2 g/kg over 10-12 hr Quinolone resistant
AND •
TREATMENT of TYPHOID FEVER in CHILDREN OPTIMAL THERAPY ALTERNATIVE EFFECTIVE DRUGS ANTIBIOTIC Daily Days Antibiotic Daily Days Dose Dose mk/day mk/day UNCOMPLICATED TYPHOID FEVER Chloramphe 50-75 14Fluoroquino 15 5-7 nicol 21 lone, eg. Ofloxacin or ciprofloxaci n Amoxicilli n 75-100 14 Fluoroquino 15 5-7 Azithromyci 8-10 7 lone or n cefixime 15-20 7-14 Cefixime 15-20 7-14 Azithromyci 8-10 7 Cefixime 20 7-14 n or ceftriaxone 75 1014 SEVERE TYPHOID FEVER Ampicillin 100 14 Fluoroquino 15 10or lone, eg. 14 Ceftriaxone Ofloxacin or ciprofloxaci n 60-75 1014 Fluoroquino 15 10Cefrtiaxone 60 10lone 14 or 14 cefotaxime 80 Ceftriaxone 60-75 10Fluoroquino 20-30 14 14 lone
Aspirin 80-100 mg/kg/day divided every 6 hr orally until patient is afebrile for at least 48 hr
CONVALESCENT STAGE •
Aspirin 3-5 mg/kg once daily orally until 6-8 wk after illness onset
Fully Sensitive
LONG-TERM THERAPY FOR PATIENTS WITH CORONARY ABNORMALITIES • • •
Aspirin 3-5 mg/kg once daily orally Clopidogrel 1 mg/kg/day (max 75 mg/day) Most experts add warfarin or low-molecular-weight heparin for those patients at particularly high risk of thrombosis
Multidrug resistant
ACUTE CORONARY THROMBOSIS •
Prompt fibrinolytic therapy with tissue plasminogen activator or other thrombolytic agent under supervision of a pediatric cardiologist
RHD Revised jones criteria Major Criteria 1. Arthritis most common 2. Carditis 3. Erythema Marginatum 4. Sydenham’s Chorea 5. Subcutaneous nodules Minor Criteria 1. Arthralgia 2. Fever < 39C 3. Elevated acute phase reactants ESR, C-reactive CHON 4. Prolonged PR interval Diagnosis via 2 major or 1 major + 2 minor Previous grp A streptococcal infection RHD 1. Mitral regurgitation/ mitral stenosis on PE 2. Left ventricular/ Right ventricular hypertrophy on ECG 3. Irregular cardiac borders on X-ray
INFECTIVE ENDOCARDITIS Infective Endocarditis 1. Strep Viridians – most common, use Pen G and gentamycin 2. Staph Aureus – 2nd most common, use Methicillin and gentamycin
Quinolone resistant
RECOMMENDED ERADICATION THERAPIES for H. pylori Medications
Dose
Amoxicillin Clarithromycin PPI
Amoxicillin Metronidazole PPI
Clarithromycin Metronidazole PPI
50 mg/kg/day in 2 divided doses 15 mg/kg/day in 2 divided doses 1 mg/kg/day in 2 divided doses or 50 mg/kg/day in 2 divided doses 20 mg/kg/day in 2 divided doses 1 mg/kg/day in 2 divided doses or 15 mg/kg/day in 2 divided doses 20 mg/kg/day in 2 divided doses 1 mg/kg/day in 2 divided doses
NEONATES
Diagnosis via 2 major or 1 major + 2 minor Previous grp A streptococcal infection
1 month
14 days 14 days 1 month
14 days 14 days 1 month
INFANTS and CHILDREN
DRUG Amikacin
0-7 days 15-20 days
8-28 days 20-30 divided q8h
Ampicillin
200-300 divided q8h 100 divided q12h
300 divided q4h or q6h 150-200 divided q8h or q6h
150 divided q12h 5 divided q12h
150 divided q8h 7.5 divided q8h
100-150 divided q8h or q12h 250,000-450,000 divided q8h
150-200 divided q8h or q6h 450,000 divided q6h
5 divided q12h 30 divided q12h
7.5 divided q8h 30-45 divided q8h
Cefotaxime
Treatment for RF 1. Pen G/ Benzathine given once (ED: 100K-400K) 2. Penicillin V/Phenoxy methyl Penicillin 2-3 times per day given for 10 days 3. Erythromycin 2-4 times per day given for 10 days
14 days
ANTIBIOTICS USED for TREATMENT of BACTERIAL MENINGITIS
ACTIVE RF
1.Joint symptoms 2. Murmurs 3. Inc. heart size 4. CHF 5. Subcutaneous Nodules 6. Sleeping pulse rate of > 100/min 7. + C-reactive protein 8. Consecutive fever for 3 days
Duration of Treatment 14 days
Ceftriaxone Ceftazidine Gentamicin Meropenem Nafcillin Penicillin G Rifampicin Tobramycin Vancomycin
1. 2. 3. 4. 5. 6.
FINDINGS: BACTERIAL MENINGITIS See Nigrovic Clinical Decision Rule CSF Color: Cloudy CSF CSF Glucose much less that 50 CSF Protein much greater that 45 CSF Leukocytes: Markedly increased Neutrophils CSF Opening Pressure: increased >200
20-30 divided q8h 300 divided q46h 200-300 divided q8h or q6h 100 divided q12h or q24h 150 divided q8h 7.5 divided q8 h 120 divided q8h 150-200 divided q4h or q6h 450,000 divided q4h or q6h 20 divided q12h 7.5 divided q8h 60 divided q6h
Albumin
1. 2. 3. 4. 5.
FINDINGS: FUNGAL MENINGITIS CSF Color: Clear to Cloudy Fluid CSF Glucose <50 CSF Protein >45 CSF Leukocytes: Monocytes increased CSF Opening Pressure: increased
1. 2. 3. 4. 5.
FINDINGS: VIRAL MENINGITIS CSF Color: Clear to Cloudy Fluid CSF Glucose: Normal CSF Protein >45 CSF Leukocytes: Increased CSF Lymphocytes CSF Opening Pressure: Normal or increased
Premature 1 day Full term <6 days <5 years old 5-19 years
1.8-3.0 g/dl 2.5-3.4 g/dl 3.9-5.0 g/dl 4.0-5.3 g/dl
Newborn Infant Child Thereafter
134-146 mmol/L 139-146 mmol/L 138-145 mmol/L 136-146 mmol/L
<2 months 2-12 months >12 months
3.0-7.0 mmol/L 3.5-6.0 mmol/L 3.5-5.0 mmol/L
Sodium
Potassium
1. 2. 3. 4.
FINDINGS: TUBERCULOSIS MENINGITIS CSF Color: Cloudy Fluid CSF Glucose <50 CSF Protein >45 CSF Leukocytes a. Early: Neutrophils increased b. Later: Lymphocytes increased
5.
FINDINGS: GUILLAIN-BARRE CSF Color: Clear to Cloudy Fluid CSF Glucose: Normal CSF Protein much greater than 45 CSF Leukocytes: Lymphocytes normal or increased CSF Opening Pressure: Normal
1. 2. 3. 4. 5.
FINDINGS: NEOPLASM CSF Color: Clear to xanthochromic CSF Glucose: Normal or decreased CSF Protein: Normal or increased CSF Leukocytes: Normal or increased lymphocytes CSF Opening Pressure: increased >200
1. 2. 3. 4. 5.
FINDINGS: NEUROSYPHILIS CSF Color: Clear to Cloudy Fluid CSF Glucose: Normal CSF Protein >45 CSF Leukocytes: Monocytes increased CSF Opening Pressure: Normal or increased
1. 2. 3. 4.
1. 2. 3. 4. 5.
FINDINGS: INTRACRANIAL HEMORRHAGE CSF Color: Bloody CSF with xanthocromia CSF Glucose: Normal or decreased CSF Protein >45 CSF Leukocytes: Increased CSF Opening Pressure: increased >200
Blood Component Replacement
Chloride Cord blood 96-105 mmol/L Newborn 97-110 mmol/L Thereafter 98-106 mmol/L Bicarbonate (HCO3) Arterial 21-28 mmol/L Venous 22-29 mmol/L Carbon Dioxide Partial Pressure (PCO2) 27-40 mmHg Newborn 27-41 mmHg Infant 35-48 mmHg Thereafter M 32-45 mmHg Thereafter F Glucose Cord blood 45-96 mg/dl Premature 20-60 mg/dl Neonate 30-60 mg/dl Newborn 1 day 40-60 mg/dl >1 day 50-90 mg/dl Child 60-100 mg/dl Adult 70-105 mg/dl Creatinine Cord blood 0.6-1.2 mg/dl Newborn 0.3-1.0 mg/dl Infant 0.2-0.4 mg/dl Child 0.3-0.7 mg/dl Adolescent 0.5-1.0 mg/dl Adult M 0.6-1.2 mg/dl Adult F 0.5-1.1 mg/dl Creatinine clearance: newborn 40-65 ml/min/1.73 m2 | <40 yr, M: 97-137, F: 88-128 Calcium Total Cord blood 9.0-11.5 mg/dl Newborn (3-24 hours) 9.0-10.6 mg/dl 24-48 hours 7.0- 12.0 mg/dl 4-7 days 9.0-10.9 mg/dl Child 8.8-10.8 mg/dl Thereafter 8.4-10.2 mg/dl Calcium Ionized Cord blood 5.0-6.0 mg/dl Newborn (3-24 hours) 4.3-5.1 mg/dl 24-48 hours 4.0-4.7 mg/dl Thereafter 4.8-4.92 mg/dl Blood Urea Nitrogen Cord blood 21-40 mg/dl Premature (1 wk) 3-25 mg/dl Newborn 3-12 mg/dl Infant or child 5-18 mg/dl Thereafter 7-18 mg/dl
RABIES EXPOSURE CATEGORY CATEGORY 1
Volume of PRBC’s= EBV (ml) x DHCT – Actual HCT of PRBC’s (0.55)
Estimated Blood Volume Age Preterm Term 1-12 mos 1-3 years 4-6 years 7-18 years
Total Blood Volume (ml/kg) 90-105 78-86 73-78 74-82 80-86 83-90
CATEGORY 2
CATEGORY 3
EXPOSURE Feeding or touching an animal Licking of intact skin Exposure to patients with s/sx of rabies by sharing or eating or drinking utensils Casual contact to patients with s/sx of rabies Nibbling or nipping of uncovered skin with bruising Minor scratches or abrasions without bleeding Licks on broken skin
Transdermal bites or scratches Mucous membranes contamination with saliva Handling of infected carcass or ingestion of raw infected meat Category II on head and neck area Exposure to rabies patient contamination of mucous membranes with saliva or fluid through platerring
MANAGEMENT Wash exposed skin immediately with soap and water NO VACCINES OR RIG NEEDED May opt to give preexposure prophylaxis COMPLETE VACCINATION UNTIL DAY 30 (If animal is rabid, died, killes, or unavailable for 14 day observation or died during period of observation within 14 days) START VACCIONE AND RIG IMMEDIATELY
GINA CLASSIFICATION OF ASTHMA SEVERITY Symptoms/D ay
Symptoms/ Nights
PEF/ FEV1
PEF Variability
>/= 80%
<20%
>2 times a month
>/= 80%
20-30%
>1 times a week
60-80%
>30%
Frequent
>30%
<1 times a week STEP 1 Intermittent
STEP 2 Mild Persistent
Asymptomatic and normal PEF between attacks >1 times a week but <1 time a day Attacks may affect activity Daily
STEP 3 Moderate Persistent
Attacks affects activity Continouos
STEP 4 Severe Persistent
Limited physical activity
LEVELS OF ASTHMA CONTROL Characteristics
Controlled (All of the Following)
Daytime symptoms Limitations of activities Nocturnal symptoms/ awakening Need for reliever/ rescue treatment Lung function* (PEF or FEV1 Exacerbation
None (≤ twice/week) None
Any
None
Any
None (≤ twice/week)
>twice/ week
Normal
<80% predicted or personal best One or more/year
Components of severity
Symptoms
Impa irme nt
Partly Controlled (Any measure present in any week) >twice/ week
None
Intermi ttent <2 days/w eek 0
Short-acting beta2agonist use for symptom control (not prevention of EIB Interference with normal activity
<2 days/w eek
Exacerbatio ns requiring oral systemic corticosteroi ds
Recommended step for initiating therapy
Three or more features of partly controlled asthma present in any week
None
48-69% 48-75% 44-72% 28-42% 35-45% 37-49% 36-46% 41-53% 36-46% 14.5-22.5 g/dl 9.0-14.0 g/dl 11.5-15.5 g/dl 13.0-16.0 g/dl 12.0-16.0 g/dl 13.5-17.5 g/dl 12.0-16.0 g/dl 9.0-30.0 x 1,000/mm3 9.4-34.0 x 1,000/mm3 5.0-19.5 x 1,000/mm3 6.0-17.5 x 1,000/mm3 5.5-15.5 x 1,000/mm3 4.5-13.5 x 1,000/mm3 4.5-11.0 x 1,000/mm3 0% 3-5% 54-62% 25-33% 3-7% 1-3% 0-0.75%
Plt ct NEWBORN: 84-478 x 10^6 (after 1 wk, same as adult)
Plt ct ADULT: 150-400x10^6
HEMODYNAMIC ASSESSMENT PARAMETERS One in any week
Classification of asthma severity (0-4 years of age)
Nighttime awakenings
Risk
Uncontrolled
Hematocrit (Hct) 1 day 2 days 3 days 2 months 6-12 months 12-18 months M 12-18 months F 18-49 years M 18-49 years F Hemoglobin (hgb) 1-3 days 2 months 6-12 years 12-18 years M 12-18 years F 18-49 years M 18-49 years F WBC Birth 12 hours 1 month 1-3 years 4-7 years 8-13 years Adult Myelocytes Neutrophils-bands Neutrophils-segmenters Lymphocytes Monocytes Eosinophils Basophils
Mild >2 days/week but not daily 12x/month >2 days/week but not daily
Minor limitation
Persistent Moderat e Daily
34x/mont h Daily
Sensorium Capillary refill time Extremities
Sever e Throu ghout the day >1x/w eek
Peripheral pulses
Severa l times per day
RR
Some limitation
Extre mely limite d 0>2 exacerbations in 6 months 1/year requiring oral systemic corticosteroids, or >4 wheezing episodes/1 year lasting >1 day AND risk factors for persistent asthma Consider severity and interval since last exacerbation, frequency and severity may fluctuate over time. Exacerbation of any severity may occur in patients in any severity category. Step 1 Step 2 Step 3 and consider short course of oral systemic corticosteroids In 2-6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4-6 weeks, consider adjusting therapy or alternating diagnoses
Heart Rate
BP
Stable condition Clear and lucid
Compensated Shock Clear and lucid
Brisk < 2 sec Warm and pink Good volume Normal for age
Prolonged > 2 sec
Normal for age
Normal systolic pressure but rising diastolic pressure Tachypnea
Normal
Hypotensive Shock
Cool peripheries
Change of mental status (restless and combative) Very prolonged, mottled skin Cold and clammy
Weak and thread
Feeble or absent
Tachycardia
Severe tachycardia with bradycardia in the late shock Narrowed PP < 20
Hyperpnea, Kussmaul breathing
CRITERIA FOR DISCHARGE All of the following must be met: No fever for at least 24-48 hours 1. Improvement in clinical status (general well-being, appetite, 2. hemodynamic status, urine output, no respiratory distress) Stable hematocrit 3. Increasing trend of platelet count (usuall y preceded by rising 4. WBC)
pCAP C
pCAP D
Pneumonia I SEVERE
Pneumonia II VERY SEVERE
NONE NONE
MODERATE MODERATE PRESENT
SEVERE SEVERE PRESENT
≥50/min to ≤60/min ≥40/min or ≤ 50/min ≥30/min or ≤ 35/min
>60/min to ≤ 70 >50/min >35/min
>70/min >50/min >35/min
NONE NONE NONE NONE NONE NONE
IC/ Subcostal PRESENT PRESENT NONE NONE IRRITABLE
Supraclavicular/IC/SC PRESENT PRESENT PRESENT PRESENT Lethargic/ Stuporous/Comastose
NONE
PRESENT
PRESENT
95%
<95%
<95%
Outpatient End of treatment
Admit to Ward
Admit to a critical care facility
pCAP A or B
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA CLASSIFICATION VARIABLES CLINICAL 1. Dehydration 2. Malnutrition 3. Pallor 4. Respiratory rate 3 to 12 mos 1 to 5 y/0 > 5 y/o
Non-Severe
NONE
Signs of respiratory failure a) Retraction b) Head bobbing c) Cyanosis d) Grunting e) Apnea f) Sensorium Diagnostic aid at site-of-care 1. Chest X-ray findings of any of the ff: effusion, abscess, air leak, or lobar consolidation
MILD
5.
2.
Oxygen saturation at room air using pulse oximetry ACTION PLAN 1. Site-of-care 2. Follow-up
GENERIC
BRAND
Aluminum hydroxide + magnesium hydroxide
MAALOX
Aluminum hydroxide + magnesium hydroxide + simethicone
MAALOX PLUS
Ambroxol Hcl
PREPARATION
EMPIRIC DOSE
FREQUENCY
<6mos=o.5ml >6mos: 1ml
QID
<6mos:o.5ml >6mos: 1ml
Brompheniramine + phenylpropanolam ine Bacillus clausii
Chloramphenicol palpitate
30mg/5ml 15mg/5ml 7.5mg/1ml
Wt x 0.2
HIMOX GLOBAPEN
250mg/ 5ml 100mg/1ml
30-50 mkd
PEDIAZITH
200mg/5ml 100mg/1ml
10mkd
OD
Cloxacillin
PEDIATAP P ZEDITAPP
Wt x 0.2
TID
Co-amoxiclav (Amoxicillin + Clavulanic Acid)
ERCEFLOR A
1-2 plastic tube
TRIDERM Betamethasone + Gentamycin +Clotrimazole
TID at lowest dose BID at high dose
Chlorphenamine + phenylephrine Chlorphenamine + Dexamethasone + Guiafenasin + Paracetamol + Phenylpropanolamine
BID
Diphenhydramine
BID for 2 weeks
Domperidone Ferrous sulfate + Folic Acid + B complex Gentamycin + Betamethasone + Clotrimazole Gentiane Radix
BISOLVON
2mg/ 1ml 4mg capsule
Wt x 0.2
RITE MED
250mg/ 5ml 125mg/5 ml 50mg/1ml
20-40mkd
Q8
CEFALIN
250mg/ 5ml 125mg/5ml 100mg/1ml
25-100mkd
Q6
TERGECEF
100mg/5ml 20mg/1ml
Infant: 8mkd
Q12
Bromhexin
Cefaclor
Cefalexin
Acute UTI: 16mkd Cefixime
8mkd
Q12 for 1 st day Q24 for 13 days
XTENDA
1gm + 10ml vial
1-5mos: 100200mkd
Q6
>/=6mos-child: 150-200mkd
Q6
Ceftriaxone
Neonates: 50100mkd
Q12
Children: 75150mkd <6y/o: 2.5mkd >6y/o: 5-10mkd
Q8 OD
ALNIX
5mg/5ml
ALNIX PLUS
5mg/5ml
<6y/o: 2.5mkd >6y/o: 5-10mkd
OD
CHLOROCAI RE
125mg/5ml
2kg: 50mkd
OD
Cetirizine diHcl Cetirizine + phenylephrine
TID
750mg/vial 250mg/vial
Cefuroxime
AMBROLE X
Amoxicillin
Azithromycin
QID
KEFOX
Q12 DISUDRIN
WT X 0.2
DYNATUSSI N
WT X 0.2
RITE MED NATRAVOX AUGMENTI N
125mg/5ml 250mg/625mg/ 5ml 625mg/tab
25-50mkd <3mos: 30mkd >3mos: 2040mkd 25-45mkd
BENADRYL
12.5mg/5ml
5mkd
VOMETA
5mg/5ml 5mg/1ml 15ml 120ml
Wt x 0.2
Ferlin drops Ferlin syrup
Premature: 24mkd Child: 3-6mkd
COMDIDER M SINUPRET
Wt x 0.2
QID BID
TID BID Q6
OD-BID OD-TID BID for 2 weeks
Ibuprofen
Leviteracetam Mupirocin Ointment Mupirocin + Betamethasone
DOLAN
200mg/5ml 100mg/5ml forte
5-10mkd
Q6 DRUGS
EMPIRIC DOSE
FREQUENCY
KEPPRA
100mg/5ml 500mg/tab
10-30mkd
BID
Amikacin
Q8 TID
FUSKINA
TID for 7 days
Amoxicillin
IV / IM: 15-22.5 mkd 30-50 mkd 40-80 mkd 40: for virgin PN cases
FUSKINA-B
BID for 2 weeks OD
100-200 mkd
Q6
20-40 mkd 25-100 mkd
BID-TID /Q8 Q6
6-8 mkd
BID
IV: 90-150 IM/IV: 50-75 mkd O: 20-40 I: 75-150
Q8 BID BID/Q12 Q8
<6y: 0.25 >6y: 5-10 O: 50-75 O: 15 mkd
OD QID BID
6-8
BID
O: 50-100 IV:100-200 30-50 mkd 20-40 mkd 25-40 mkd
QID Q4/Q6 Q12 BID TID BID
IV: 0.04-0.2 PO: 0.12-0.8 mkd Rectal: 0.5 1mkd 5 mkd 20-40 mkd 30-50 mkd 1-2 mkd 7.5 mkd IV: 5-8 5-10
Q2-4 Q6-8
10-15 60 35-50 15-20 Giardia 50-100 mkd IV: 100-200 10-20
MONTAIR
4mg 5mg 10mg
Monmtelukast Mometasone furoate
OD
10mg/sachet 30mg/sachet 100mg/cap 2.25% 0.5ml via nebulizer
Racecadotril
Racemic Epinephrine
KIDZKIT 3 (1st 2 mos) KIDZKIT2
200mg/5ml 200mg/5ml 250mg/5ml 200mg/5ml 200mg/5ml
PECOF
1.5mkd
Zinc Sulfate
E-Zinc
TID
<4yrs: 0.05mkd + 3ml NSS over 15 min PRN
Q1-2
PEDZINC
Ceftazidime Ceftriaxone Cefuroxime
Chloramphenicol Q3-4 OD
Clarithromycin Cotrimoxazole Cloxacillin
Co-amoxiclav
TID for 35 days 55mg/5ml 27.5mg/1ml <6mos: 10 elemental zinc >6mos: 10 elemental zinc
Zinc Sulfate + Vitamin C
Cefixime
Cetirizine
>4yrs: 0.5ml/dose +3ml NSS over 15 mins PRN 10mkd 10mkd 15mkd 10mkd 10mkd WT X 0.2
Calmoseptine
Cefaclor Cefalexin
ELICA
HIDRASEC
Rifampicin Isoniazid + Pyrazinamide Rifampicin Isoniazid Salbutamol + Guiafenasin+ Bromhexin Zinc Oxide + Calamine
6mos-5yrs: 4mg 6-14yrs: 5mg >14yrs: 10mg
Ampicillin
Diazepam Diphenhydramine Diloxanide Erythromycin Furosemide Gentamicin Ibuprofen INH (Isoniazid) Meropenem
STRICT
DENGUE PRECAUTIONS STRICT
ALLERGIC PRECAUTIONS
1. 2. 3. 4. 1. 2.
3. 4. 5. 6.
STRICT
7. 8. 1.
ENTERIC
2.
PRECAUTIONS 3. 4. 5. 6.
Throw cans or tires to avoid breeding grounds for mosquitoes Cover water containers Use insecticides to kill the vector Use mosquito repellants and mosquito nets Avoid exposure to cold air, smoke, and pollens Avoid hair sprays, gel, strong perfume, fabric softener, powders, cosmetic, and chalk dust Wear warm clothing Use hypoalleregenic sheets and pillows Do not use wool blankets and furry stuffed toys Keep child away from dogs, cats, hamsters, mice and other pets Wash curtains and shampoo rugs Clean child’s room regularly Proper hand washing before eating and after using the toilet Proper hand washing before handling and preparing food and cleaning utensils used for preparation and cooking of food Boil drinking water for 15 minutes or more Cook food thoroughly Wash all fruits and vegetables to be eaten raw Keep fingernails clean and short
Metronidazole Oxacillin
Piperacillintazobactam PPA (Phenylpropanolamine) Pyrazinamide Ranitidine Rifampicin SMX-TMP Zinc
100,000-400,000 ukd 300,000-400,000 ukd – meningitic dose <6y: 150-300 mkd IV >6y: 300-400 mkd IV 12 15 O: 2-4 IV: 2-6 10-20 6-8 mkd 10: < 6 months old 20: > 6 months old
50/1 100mg/ml - drops 125/5 250/5 - suspension 125/5 250/5 125/5 187/5 250/5 375/5 125/5 250/5 100/5 20/1
125/5 (750mg/vial) 250/5 2.5/ml 5/5 125/5 125/5 250/5 400/80/5 200/40/5 125/5 156.25/5 228/5ml 312.5/5 – 250mg Amox 457/5 – 400mg Amox 1/1 5/1
Stat Q6 TID Q6-8
6.25/5 12.5/5
Q8
QID
10/1 40/1 100/5 200/5 50/5
TID
125/5
Q6 Q4/Q6 Q4
250/5
Q6
Paracetamol
Pen G Na
PREPARATION
100/1 -drops 120/5 250/5
Q4-6
BID-TID
12.5/5 250/5
BID OD
200/40/5 55/5
