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TABLE OF CONTENTS I. ADMITTING ORDERS NEONATOLOGY NICU..................... NICU................................... ........................... .......................... .......................... .......................... ............. NEUROLOGY FEBRILE SEIZURES................ SEIZURES............................. .......................... ............................ .......................... ........... LUMBAR TAP...................... TAP................................... .......................... .......................... .......................... ............... PULMONOLOGY BRONCHIAL ASTHMA.................. ASTHMA............................. ......................... .......................... ................... ....... BPN....................... BPN..................................... .......................... ......................... ............................ ........................... ............ GASTROENTEROLOGY AGE..................... AGE.................................. ........................... ........................... .......................... ............................ ............... IMMUNOLOGY HYPERSENSITIVITY REACTION.................... REACTION............................... ........................ .................. ..... INFECTIOUS DISEASES DENGUE FEVER.................. FEVER............................... .......................... .......................... ........................... .............. II. MEDICATIONS ANTIBACTERIAL CELL WALL ACTIVE ANTIBIOTICS PENICILLIN.................. PENICILLIN............................... ........................ ........................ ............................. ................ Amoxicillin........... Amoxicillin....................... ........................... ............................. ..................... ....... Cloxacillin............ Cloxacillin......................... ............................ ............................ .................... ....... Flucloxacillin.......... Flucloxacillin....................... .......................... .......................... .................... .......

11 12 13 14 15 16 17 18

20 20 20 20

PENICILLIN COMBINATIONS

Amx + CA...................... CA................................... ............................ .......................... ........... CEPHALOSPORINS 1ST GEN Cefalexin................. Cefalexin.............................. .......................... .......................... ................... ...... 2ND GEN Cefaclor........

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PROTEIN SYNTHESIS INHIBITOR MACROLIDES Erythromycin.............. Erythromycin........................... .......................... .......................... ............... .. Clarithromycin............ Clarithromycin......................... .......................... .......................... ............... .. Roxithromycin............. Roxithromycin.......................... .......................... .......................... ............... Azithromycin.............. Azithromycin.......................... ......................... ............................. ................ LINCOSAMIDES Clindamycin.............. Clindamycin.......................... ......................... .......................... .................. ..... CHLORAMPENICOL........... CHLORAMPENICOL.......................... ............................ .......................... .................... ....... TETRACYCLINE................. TETRACYCLINE.............................. ........................... .......................... ..................... ......... Doxycycline................... Doxycycline................................ .......................... ......................... ............ DNA SYNTHESIS INHIBITOR NITROFURAN Furaxolidone........... Furaxolidone........................ .......................... .......................... .................. ..... Ercefuryl.................. Ercefuryl................................ .......................... ......................... .................. ..... ANTIBACTERIAL COMBINATIONS TMP - SULFAMETHOXAZOLE SULFAMETHOXAZOLE Cotrimoxazole............. Cotrimoxazole.......................... .......................... .......................... ............... TMP – TMP – SULFADIAZONE............... SULFADIAZONE............................. .......................... ......................... .................... ....... IV ANTIBIOTICS.................. ANTIBIOTICS............................... .......................... .......................... .......................... ...................... ......... ANTITUBERCULOSIS Isoniazid.................. Isoniazid............................... .......................... .......................... .................. ..... Rifampicin.............. Rifampicin............................. ............................ .......................... ................. .... Pyrazinamide............... Pyrazinamide............................ .......................... .......................... ............... ANTIPROTOZOAN AMOEBICIDES Metronidazole.............. Metronidazole........................... .......................... .......................... ............. Etofamide............... Etofamide............................ .......................... .......................... ................... ...... Diloxanide Furoate.................... Furoate................................. .......................... ............. Secnidazole.................. Secnidazole............................... ............................ ........................... ............ Ercefuryl.................. Ercefuryl................................ ........................... .......................... ................. ....

22 22 22 22 23 23 23 23

23 23

24 24 24 25 25 25

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ANTIFUNGAL Ketoconazole................. Ketoconazole.............................. ............................ ......................... .......... Nystatin..................... Nystatin................................. ............................ ............................. ............... Fluconazole................ Fluconazole............................ ......................... .......................... ................ ... NEUROLOGY ANTICONVULSANT Diazepam.................... Diazepam.................................. ........................... .......................... ............. Midazolam.............. Midazolam........................... .......................... .......................... ................... ...... Phenobarbital.............. Phenobarbital........................... .......................... .......................... ............... Phenytoin.................. Phenytoin............................. ........................ .......................... .................. ..... Carbamazepine.............. Carbamazepine........................... ........................... ......................... ........... Oxcarmazepine............... Oxcarmazepine............................ ............................. ........................ ........ Valproic Acid.................... Acid................................... ............................. .................... ...... Topiramate.................. Topiramate............................... .......................... ........................... .............. RESPIRATORY DRUGS NASAL NaCl...................... NaCl.................................... ........................... .......................... .................... ....... Oxymetazoline............... Oxymetazoline............................ ........................... ......................... ........... Xylometazoline.............. Xylometazoline........................... ........................... ......................... ........... ORAL Phenylpropanolamine....... Phenylpropanolamine.................... ........................... ..................... ....... Bromphenamine Bromphenamine Maleate + Pheylephrine............ Pheylephrine............ Carbinoxamine Carbinoxamine maleate + Phenylephrine HCl...... Loratadine + PPA.................... PPA................................... ............................ ............... MUCOLYTIC Carbocisteine................ Carbocisteine............................. .......................... .......................... ............. Ambroxol............... Ambroxol............................ .......................... .......................... .................... ....... B2 AGONIST Salbutamol.............. Salbutamol........................... .......................... .......................... .................. ..... Terbutaline................. Terbutaline.............................. .......................... .......................... ............... .. Doxofylline.............. Doxofylline........................... .......................... .......................... .................. .....

27 27 27

28 28 28 29 29 29 30 30

32 32 32 33 33 33 33 34 35 36 36 36































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IMMNULOGY ANTIHISTAMINE Diphenhydarmine.......... Diphenhydarmine....................... ............................ ......................... .......... Hydroxyzine................ Hydroxyzine........................... ........................ .......................... ................. .... Ceterizine................... Ceterizine............................... ......................... ............................. ................ Loratadine.................. Loratadine............................. ......................... ........................... ................ ... Desloratadine................. Desloratadine.............................. ............................ ........................ ......... STEROIDS INHALED Budesonide................ Budesonide............................ ......................... .......................... ................. .... ORAL Prednisone................. Prednisone............................. ......................... .......................... ................ ... Prednisolone.............. Prednisolone.......................... ............................ ............................. ............... INTRAVENOUS Hydrocortisone............. Hydrocortisone.......................... ............................. .......................... .......... IVIG INFUSION................. INFUSION.............................. ............................ .......................... ....................... ............ CARDIOVASCULAR DRUGS ANTIHYPERTENSIVE Hydralazine............... Hydralazine........................... ......................... .......................... ......................... ............ Spirinolactone............ Spirinolactone........................ ......................... .......................... ........................ ........... GASTROINTESTINAL DRUGS ANTACIDS MgOH + AlOH...................... AlOH.................................. .......................... ............................ .............. Simethicone............... Simethicone.......................... ........................ ........................... ......................... ........... ANTISPASMODIC Dicycloverine................. Dicycloverine.............................. ........................... ............................ .................. .... Domperidone............. Domperidone......................... ......................... .......................... ........................ ........... H2-BLOCKER Ranitidine............... Ranitidine............................ .......................... .......................... .......................... ............. Cimetidine............. Cimetidine.......................... .......................... .......................... ........................... ..............

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OTHER GI DRUGS PARENTERAL NUTRITIONAL PRODUCTS LYSMIX.................. LYSMIX................................ ........................... .......................... ................... ...... SUPPLEMENTS & ADJUVANT THERAPY PROBIOTICS Prozinc...................... Prozinc.................................. ......................... .......................... ............. Erceflora.................... Erceflora............................... ........................ .......................... ............. PRETOXIN..................... PRETOXIN.................................. .......................... .......................... ............. ANTIPYRETIC/ANALGESIC Paracetamol.................. Paracetamol............................... ............................. ........................... ................. ...... Mefenamic Acid................... Acid................................ ........................... .......................... ............ Aspirin................. Aspirin............................... ........................... ............................ ............................ ............. Ibuprofen............... Ibuprofen............................ ........................... ........................... .......................... .............

44

45 45 45

46 46 47 47

DRIPS Dengue...................... Dengue.................................. ......................... ............................. ........................ ........ Furosemide................ Furosemide........................... ........................ ............................. ......................... ......... Noradrenaline.............. Noradrenaline........................... .......................... ............................ ..................... ...... Dopamine.................. Dopamine............................. ........................ .......................... ......................... ............ Dobutamine.............. Dobutamine.......................... ......................... .......................... ......................... ............ Terbutaline................ Terbutaline............................ ......................... .......................... ........................ ........... Precedex...................... Precedex................................... .......................... .......................... ..................... ........ Ketamine................ Ketamine.............................. .......................... ......................... .......................... ............. Morphine............... Morphine............................ ......................... ......................... ............................ ............... Naproxen................... Naproxen............................... ........................... ............................ ...................... .........

48 49 49 49 49 49 50 50 50 50

ELECTROLYTES KCl..................... KCl.................................. .......................... ............................. ............................. ............... .. NaHCO3.................... NaHCO3................................ ......................... ............................. ......................... ......... Ca GLUCONATE.................. GLUCONATE............................... ............................ ........................... ..............

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III. CONDITIONS NEONATOLOGY Essential Newborn Care Protocol (DOH)....................... (DOH)............................. ...... Newborn Care..................... Care................................... ........................... .......................... .................... ....... Apgar Score..................... Score.................................. ............................ ............................ ....................... .......... Newborn Screening................... Screening................................ .......................... .......................... ............... .. Nursery Notes Dextrosity................... Dextrosity................................ .......................... .......................... ...................... ......... Electrolyte Requirements................ Requirements............................. ........................... ...................... ........ Glucose Infusion Rate......................... Rate...................................... ........................... ................... ..... Emergency Intervention Level of Umbillical Catheterization....................... Catheterization.............................. ....... ET Tube Determination........... Determination........................ ........................... ....................... ......... Total Flow Rate...................... Rate................................... .......................... ........................ ........... Extubation............. Extubation........................... ........................... .......................... .......................... ............. Cows Milk Allergy.................. Allergy.............................. ......................... .......................... .................... ....... Hyperbilirubinemia Bilirubin Metabolism............. Metabolism.......................... .......................... ......................... ............ Neonatal Jaundice................. Jaundice............................... ........................... ........................ ........... Kramer Classification............. Classification.......................... .......................... ......................... ............ Bilirubin Values...................... Values................................... .......................... ........................ ........... Physiologic vs Pathologic Jaundice............................. Jaundice............................... Breastfeeding vs Breastmilk Jaundice.......................... Jaundice.......................... Treatment of Hyperbilirubinemia...... Hyperbilirubinemia......

54 54 56 56 57 59 59 59 60 60 60 61 61 62 62 63 63 64 65































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Cerebrspinal Fluid CSF PATHWAY.................. PATHWAY................................ ............................ ............................ ................ LUMBAR PUNCTURE.................. PUNCTURE............................... .......................... ..................... ........ CSF ANALYSIS................. ANALYSIS............................... ............................ .......................... ................. ..... Hydrocephalus............. Hydrocephalus.......................... .......................... .......................... .......................... ............... .. Bells Palsy...................... Palsy................................... ............................ .......................... ........................ ............. Cerebral Palsy...................... Palsy................................... .......................... .......................... .................... ....... Hypoxic Ischemic Enchepalopathy.............. Enchepalopathy........................... ........................ ........... PULMONOLOGY PCAP Clinical Features of Pneumonia................ Pneumonia............................. ................... ...... Microbial Causes of CAP aacdg to Age....................... Age......................... .. CXR In Assessing CAP etiology.............................. etiology..................................... ....... Therapeutic Mngt of CAP...................... CAP..................................... ...................... ....... CPG....................... CPG.................................. .......................... ............................ .......................... ............... .. ASTHMA Severity of Asthma Exacerbation................ Exacerbation........................... ................. ...... Levels of Asthma Control (GINA).................... (GINA)................................. ............. Management Approach Based on Control................... Control................... BRONCHIOLITIS............... BRONCHIOLITIS............................ ............................ .......................... ....................... ............ VIRAL CROUP VS EPIGLOTITIS..................... EPIGLOTITIS.................................. ........................ ........... BICARBONATE DEFICIT CORRECTION..................... CORRECTION.................................. ............. CARDIOVASCULAR

71 71 71 72 73 74 75

77 77 78 78 80 82 83 83 84 85 86































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GASTROENTEROLOGY Assessment of Dehydration................ Dehydration............................ ......................... .................... ....... Caposition of ORS...................... ORS................................... .......................... .......................... ............... .. Oral Rehydration Theraphy................... Theraphy................................. ........................... ............... .. Fluid Management............... Management............................ .......................... .......................... .................... ....... Composition of IV Solution.............. Solution............................ ........................... ..................... ........ Maintenance Water.................... Water................................... .......................... ........................ ............. NEPHROLOGY GFR Normal Values..................... Values.................................... .......................... ........................ ............... Computations GFR...................... GFR.................................... ............................. ............................ .......................... ............. OFI..................... OFI.................................. .......................... ............................ .......................... ................ ..... BSA...................... BSA.................................. .......................... ........................... ........................... ................ .. AGN....................... AGN.................................... .......................... ........................... ........................... .................... ....... GABS..................... GABS.................................. .......................... ........................... ........................... ..................... ........ INTERPRETAtION OF BUN-CREA RATIO........ R ATIO.................... ....................... ........... IMMUNOLOGY Anaphylaxis................ Anaphylaxis............................ ........................... ............................ ........................... ................ .. Dermatitis................... Dermatitis................................. ........................... .......................... ........................... ................ Atopic................... Atopic................................. ........................... .......................... .......................... ............... Contact...................... Contact.................................. ......................... ............................ ........................ ......... Seborrheic................. Seborrheic............................. .......................... ........................... ....................... .......... Juvenile Rheumatoid Arthritis.................. Arthritis............................... .......................... ............. Systemic Lupus Erythematosus....

93 93 94 94 95 95 96 96 96 96 97 98 99 100 101 101 101 101 102 103































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Roseola (HSV 6)...................... 6)..................................... ............................ ........................... ................ .. Coxsackie A (Herpangina)................ (Herpangina)............................. .......................... ...................... ......... Herpes Simplex Virus (Varicella)..................... (Varicella).................................. .................... ....... Parvovirus B19 (Erythema Infectiosum/Fifth Disease)........ Dengue Fever..................... Fever................................... ........................... .......................... ..................... ........ NUTRITION Waterloo Classification............ Classification........................... ............................ ........................... ................ Growth & Caloric Requirements.................. Requirements............................... ....................... .......... Caloric & Protien Requirements................ Requirements............................ ......................... ............. Estimated Catch Up Growth Requirement................ Requirement.......................... .......... Approximate Daily Water Requirement.................. Requirement.............................. ............ Osterized Feeding.................... Feeding.................................. ........................... .......................... ............... .. Milk Formulas............... Formulas............................. ............................ .......................... ......................... ............. Total Parenteral Nutrition............... Nutrition............................ .......................... ...................... ......... TPN in Pediatrics................... Pediatrics................................ ........................... ........................ .......... TPN for Neonates....................... Neonates.................................... ........................... .................... ...... Sample Solving................. Solving................................ ............................ .......................... ............... .. EMERGENCY MEDICINE ET Tube Determination........... Determination........................ ............................ ............................ ............... .. Laryngoscope Sizes..................... Sizes.................................... ........................... ......................... ............. Emergency Management.................. Management............................... ............................ ..................... ...... Epinephrine Amiodarone

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117 117 118 118 118 119 120 121 122 125 126 128 128 128































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ADMITTING ORDERS NEONATOLOGY NICU Please admit under RI, LI, PD or AP TPR q4H May breastfeed if NSD; NPO x 2hrs if CS Labs: NBS at 24 hrs old, secure consent CBC, BT (if w/ maternal illness, PROM or UTI HGT now then 1, 3, 6, 12, 24, 24, 48 hrs old (GDM) HGT now (SGA or LGA) Medications: Erythromycin eye ointment both eyes Vit K 1 mg IM (term); 0.5 mg (PT) Hep B vaccine 0.5 ml IM, secure consent BCG 0.05 ml ID (PT); 0.1 ml (term), secure onsent SO Routine NB care Monitor VS q30 mins until stable Thermoregulate at 36.5 to 37.5°C Place under droplight (NSD); isolette (CS)

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NEUROLOGY FEBRILE SEIZURE Please admit under the service of Dr. TPR q4H and record DAT once fully awake Labs: CBC U/A (MSCC) IVF: D5 0.3 NaCl 1P 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol Paracetamol prn q4h for T > 37.8°C

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Pre Lumbar Tap NPO RBS by gluco prior to lumbar tap Prepare lumbar tap set 2% Lidocaine # 1 G 23 spinal needle Mannitol 250 cc 1 bottle - do not open Solvent Diazepam 1 amp 3cc syringe #2 2 manometers sterile bottles # 3 sterile gloves # 2 Sterile gauze # 1 Sterile gauze w/ Betadine #1 Sterile towel w/ hole #1

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PULMONOLOGY BRONCHIAL ASTHMA Please admit under the service of Dr. TPR q4H and record NPO if dyspneic Labs: CBC CXR APL* ABG* U/A (MSCC) IVF: D5 0.3 NaCl 1P 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – (10 – 15 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses Incorporate Budesonide 10 mkd LD (max 200mg IV); then 5mkd































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BPN Please admit under the service of Dr. TPR q4H and record NPO if dyspneic Labs: CBC U/A (MSCC) ABG* CXR APL* IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) OR D5 IMB/D5 NM at MR if with NO losses D5 0.3 NaCl 1L 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – (10 – 15 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses































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GASTROENTEROLOGY AGE Please admit under the service of Dr. TPR q4H and record DAT once fully awake; NPO x 2hrs if with vomiting Labs: CBC U/A (MSCC) F/A (Concentration Method) IVF: D5 0.3 NaCl 1P 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C Zinc (E Zinc)

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IMMUNOLOGY HYPERSENSITIVITY REACTION Please admit under the service of Dr. TPR q4H and record Hypoallergenic diet Labs: CBC U/A (MSCC)

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INFECTIOUS DISEASES DENGUE FEVER Please admit under the service of Dr. TPR q4H and record DAT ( No dark colored foods) Labs: CBC, Plt (optional APTT and PT) Blood typing

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MEDICATIONS ANTIBACTERIALS CELL WALL ACTIVE ANTIBIOTICS PENICILLINS Amoxicillin (30 – (30 – 50 50 mkday) TID Pediamox Susp : 250mg/5ml Drops : 100mg/ml

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CEPHALOSPORINS 1st Generation Cefalexin (25 – (25 – 100 100 mkd ) q 6-8 h Lexum Cap : 250mg; 500mg Cefalin Susp : 125mg/5ml 250mg/5ml Keflex Drops : 100mg/ml Ceporex Cap : 250mg 500mg

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PROTEIN SYNTHESIS INHIBITOR

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LINCOSAMIDES

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ANTIBACTERIAL COMBINATIONS

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ANTI-TB MEDS

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ANTIPROTOZOAN

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NEONATAL JAUNDICE Risk Factors o o o o o o o o

ZONE I II III IV V

Jaundice visible on first day of life A sibling w/ neonatal jaundice or anemia Unrecognized hemolysis Non-optimal feeding Deficiency: G6PD Infection Cephalhemaoma or bruising / Central hct >65% East Asian/ Mediteranean in origin

KRAMER CLASSIFICATION CLASSIFICATION JAUNDICE Head/neck Upper trunk Lower trunk, thigh Arms, leg, below knee Hands/feet

mg/dl 6 – 8 – 8 9 – 12 – 12 12 – 12 – 16 16 15 – 15 – 18 18 > 15































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Bilirubin (Total) Cord

Preterm Term Preterm Term Preterm Term Preterm Term Preterm Term

0 – 1 – 1 days 1 – 2 – 2 days 3 – 5 – 5 days Older Infants Adult Bilirubin (Conjugated) Neonate Infants/Children

FACTORS Onset Rate of inc of TSB Persistent Total S. Bilirubn Sign/ Symptom

<2 mg/dl <2 mg/dl <8 mg/dl <8.7 mg/dl <12 mg/dl <11.5 mg/dl <16 mg/dl <12 mg/dl <2 mg/dl <1.2 mg/dl 0.3 – 0.3 – 1.2 mg/dl

<34 µmol/L <34 µmol/L <137 µmol/L <149 µmol/L <205 µmol/L <197µmol/L <274 µmol/L <205µmol/L <34 µmol/L <21 µmol/L 5 – 12 – 12 µmol/L

<0.6 mg/dl <0.2 mg/dl

<10 µmol/L <3.4 µmol/L

PHYSIOLOGIC vs PATHOLOGIC PHYSIOLOGIC PATHOLOGIC > 24 hrs of life < 24 hrs of life < 0.5mg/dl/hr > 0.5mg/dl/hr < 14 days FT: > 8 days PT: > 14 days FT: < 12 mg/dl Any level requiring PT: < 14 mg/dl phototherapy Vomiting, lethargy, poor feeding, excess wt loss, apnea,































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Parameter Onset

Pathophysio

Mngt

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BREAST FEEDING vs BREASTMILK JAUNDICE BREASTFEEDING BREASTMILK 3rd to 5th day of Late; start to rise on day 4; may reach 20 – 20 – 30 30 life mg/dl on day 14 then ↓ slowly Normal by 4 – 4 – 12 12 weeks Decrease milk Unknown intake → Prob. due to β – glucoronidase in BM which ↑ ↑enterohepatic enterohepatic circulation circulation Normal LFT; (-) hemolysis Fluid and If breastfeeding is stopped, rapid decrease in caloricsupplement bilirubin level in 48 48 hrs, if resumed resumed will rise to 2 – 4 – 4 mg/dl but no precipitating previous events































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Treatment of Hyperbilirubinemia Phototherapy o Complications: metabolic acidosis, electrolyte abnormalities, hypoglycemia, hypocalcemia, Exchange thrombocytopenia, volume overload, arrhythmias, NEC, transfusion infection, graft versus host disease, and death o

IV Ig

o o o

Metalloporphyrins o

Adjunctive treatment for hyperbilirubinemia due to isoimmune hemolytic disease (0.5 –1.0 –1.0 g/kg/dose; repeat in 12 hr) Reducing hemolysis Competitive enzymatic inhibition of the rate limiting conversion of heme-protein to biliverdin (an intermediate metabolite to the production of unconjugated bilirubin) by heme-oxygenase Patients with ABO incompatibility or G6PD deficiency or when blood products are discouraged as with Jehovah's Witness patients

PHOTOTHERAPY o 10 Bulbs o 20 watts o 200 hrs o 30 cms o Bilirubin in the skin absorbs light energy o Photo-isomerization reaction converting the toxic native unconjugated 4Z, 15Zbilirubin into an unconjugated configurational isomer 4Z,15E-bilirubin, which can then be excreted in bile without conjugation o major product from phototherapy is lumirubin, which is an irreversible structural isomer converted from native bilirubin and can be excreted by the kidneys in the unconjugated state































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NEONATAL SEPSIS Classification Early: birth to 7th day of life  Late: 8th to 28th day of life  Risk factors Maternal infection during pregnancy  Prolongrupture of membranes (18 hrs)  Prematurity  Common organism: Bacteria: GBS, E. coli & & Listeria (early)  Viruses: HSV, enteroviruses  Signs & symptom Non-specific  Dx: CBC, CXR, blood and urine culture, lumbar tap for CSF studies  Treatment Empiric antibiotics [Ampicillin + 3rd gen Cephalosporin or Aminoglycoside)  supportive 

































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NEUROLOGY Glasgow Coma Scale Response Activiy Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1 Verbal Oriented 5 Confused 4 Inappropriate 3 words 2 Inappropriate 1 sounds None Motor Follows 6 command 5 Localizes pain 4 Withdraws to 3

Infants Activity

Response

Spontaneous To speech To pain None

4 3 2 1

Coos, babbles Irritable Cries to pain Moans to pain None

5 4 3 2 1

Normal spontaneous movement Withdraws to touch

6 5 4 3































P e d i a t r i c

MOTOR full resistance with gravity some resistance with gravity movement with gravity movement w/o gravity flicker no movement

N o t e s | 68

DTR 5/5 4/5 3/5 2/5 1/5 0/5

very brisk brisker than average normal diminished no response

CRANIUM Caput succedaneum diffuse edematous swelling of soft tses of scalp  extend across midline  st edema disappears w/in 1 few days of life  molding and overriding of parietal bones-frequent  st disappear during 1 wks of life  no specific tx  Cephalhematoma subperiosteal hemorrhage  limited to1 cranial bone  occur 1-2 % cases  no discoloration of overlying scalp  swelling not visible for several hours after birth ( blding slow 

+4 +3 +2 +1 0































P e d i a t r i c

N o t e s | 69

HYDROCEPHALUS Result from impaired circulation circulation & absorption of CSF or from inceased inceased  production Obstructive or Noncommunicating  o Due to obstruction w/n ventricular system o Abnormality of the aqueduct or a lesion in the 4th venticle (aqueductal stenosis) Non-obstructive or Communicating  o Obliteration of the subarachnoid cisterns or malfunction of the arachnoid villi o Follows SAH that obliterates arachnoid villi; leukemic infiltrates Clinical Manifestation Infant: accelerated rate of enlargement of the head; wide anterior  fontanel & bulging [Normal fontanel size: 2 x 2 cm] Eyes may deviate downward: due to impingement of the di lated  suprapineal recess on the tectum [setting – sun sun sign] Long – Long – tract tract sign: [brisk DTR, spasticity, clonus, Babinski sign]  Percussion of skull produce a “crackedpot” or Macewen sign *separation  of sutures] Foreshortened occiput [Chiari malformation]  Prominent occiput [Dandy-Walker malformation]  Treatment Depends on the cause 































P e d i a t r i c

N o t e s | 70

SEIZURE SEIZURE BENIGN FEBRILE SEIZURE CRITERIA 6 mos – mos – 6 6 yrs  < 15 mins  Febrile  Family history of febrile seizure  GTC  Not > 1 episode in 1 febrile episode; EEG done after 2 wks of seizure  episode 3% of general population develop epilepsy  1 – 2 – 2 % of BFS develop epilepsy  25% recurrence of seizure  – paroxysmal, time limited change in motor activity and/or Seizure – paroxysmal,  behavior that results from abnormal electrical activity in the brain – present when 2 or more unprovoked seizure s occur at an Epilepsy – present  interval greater than 24 hrs apaet

SIMPLE

COMPLEX































P e d i a t r i c

N o t e s | 71

CSF PATHWAY rd Choroid plexus (lateral ventricle) → Foramen of Monroe → 3 ventricle th → Aqueduct of sylvius → 4 ventricle →Foramina of Luschka (2 laterals) → & Magendie (median) → SAS → Absorbed in the arachnoid villi, then in the Venous System

Contraindications Contraindications to LP   

evidence of Inc ICP severe CP compromise Skin infection at site of puncture

Normal Infant (Term)

Color

CSF ANALYSIS Rbc Wbc

Diff ct

Sugar

Xantho

0 -100

L 100%

70 -80%

0 -32

CHON 60 150

































P e d i a t r i c

 



 

N o t e s | 72

HYDROCEPHALUS Result from impaired circulation & absorption of CSF or from inceased production Obstructive or Noncommunicating Noncommunicating o Due to obstruction w/n ventricular system o Abnormality of the aqueduct or a lesion in the 4th venticle (aqueductal stenosis) Non-obstructive or Communicating Communicating o Obliteration of the subarachnoid cisterns or malfunction of the arachnoid villi o Follows SAH that obliterates arachnoid villi; leukemic infiltrates Clinical Manifestation Infant: accelerated rate of enlargement of the head; wide anterior fontanel & bulging [Normal fontanel size: 2 x 2 cm] Eyes may deviate downward: due to impingement of the dilated































P e d i a t r i c

      

N o t e s | 73

BELLS PALSY Acute unilateral facial nerve palsy that is not associated with other cranial neuropathies or brainstem dysfunction Usually develops abruptly about 2 wks after SVI [EBV, HSV, mumps] Upper and lower portions of the face are paretic Corner of the mouth droops Unable to close the eye on the involved side Protection of cornea with methylcellulose eye drops or an ocular lubricant Excellent prognosis































P e d i a t r i c

N o t e s | 74

CEREBRAL PALSY 

Non-progressive disorder of posture & movement often associated with epilepsy & abnormalities of speech, vision & intellect i ntellect resulting from defect or lesion of the developing brain Etiology: infections, toxins, metabolic, ischemia  Classification Physiologic Topogrphic [major motor abnormality] [involved extremities] 1. Spastic 1. Monoplegia [1 side/portion] 2. Athetoid – Athetoid –worm worm like 2. Paraplegia 3. Rigid 3. Hemiplegia 4. Ataxic 4. Triplegia [3 limbs] 5. Tremor 5. Quadriplegia [all] 6. Atonic 6. Diplegia [LE/UE] 7. Mixed 7. Double hemiplegia 8. unclassified Clinical Manifestaion































P e d i a t r i c

Criteria for Hypoxic Ischemic Encephalopathy pH < 7 (profound met. Acidosis) Apgar <3 more than 5 mins Neurologic sequelae (coma; sz) Multiorgan involvement Difficult delivery     

Medications 



Dopamine: wt x dose x 0.075 Prep’n : Single Strength: 200mg/250ml; Double Strength: 400/250ml if using double strength: wt x dose x 0.075÷2 (Dose = 5-20) Dobutamine: wt x dose x 0.06 Prep’n: 250mg/250 ml; Dobuject 50mg/ml (Dose = 5-20)

N o t e s | 75































P e d i a t r i c

N o t e s | 76

































P e d i a t r i c

N o t e s | 77

PULMONOLOGY PCAP CLINICAL FEATURES of PNEUMONIA o Bacterial Fever >38.5C o Chest recession o Wheeze not a sign of primary bacterial bacterial URTI o Viral Wheeze o fever < 38.5 o marked recession

































P e d i a t r i c

N o t e s | 78

CXR in assessing CAP etiology Alveolar infltrates Bacterial pneumonia Interstitial infiltrates Viral pneumonia Both infiltrates Viral, Bacterial or mixed viral bacterial pneumonia

Therapeutic Mgt of CAP OPD Mngt Birth to 20

Admit

































P e d i a t r i c

VARIABLE

Comorbid Illness Compliant caregiver Ability to

PCAP A Minimal Risk

PCAP PCAP B Low Risk

None

N o t e s | 79

PCAP C Moderate Risk

PCAP D High Risk

Present

Present

Present

Yes

Yes

No

No

Possible

Possible

Not

Not

































P e d i a t r i c

N o t e s | 80

Clinical Practice Guidelines in the Evaluation and Management of PCAP 2004 Predictors of CAP in patients with cough (3 mos to 5 yrs) – yrs) – tachypnea tachypnea &/or chest retractions  (5 – (5 – 12 12 yrs) – yrs) – fever, fever, tachypnea & crackles  (>12 yo) – yo) – (a) (a) fever, tachypnea & tachycardia; (b) at least 1 AbN CXR  WHO Age Specific classification for tachynea 2 – 12 – 12 mos: >50 RR  1 – 5 yrs: >40 RR  >5 yrs: >30 RR 

































P e d i a t r i c

What shud b done if px is not responding to current antibiotics 1. If PCAP A/PCAP A/PCAP B not responding w/n 72 hrs a. Change initial antibiotic b. Start oral Macrolide c. Reevaluate dx 2. PCAP C no responding w/n 72 hrs consult w/ specialisr a. PCN resistant S pneumonia b. Complication c. Other dx

N o t e s | 81



































P e d i a t r i c

ASTHMA

N o t e s | 82



































P e d i a t r i c

LEVELS OF ASTHMA CONTROL [GINA GUIDELINES]

N o t e s | 83



































P e d i a t r i c

BRONCHIOLITIS

N o t e s | 84



































P e d i a t r i c

VIRAL CROUP vs EPIGLOTTITIS

N o t e s | 85



































P e d i a t r i c

BICARB DEFICIT CORRECTION:

N o t e s | 86









































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































P e d i a t r i c

N o t e s | 122

TPN in Pediatrics A. Energy Requirment AGE/WT Caloric Rquirement Neonates 90-120 kcal/kg Infants & Older Children

10-120 kcal/kg 1000kcal + 50 kcal foe each kg > 10 1500 + 20 for each more than 20

<10 kg 11-20 kg >20 B. Fluid Requirement AGE/WT Fluid Rquirement Neonates VLBW (≤ 1500 Initiate at 40 – 40 – 60 60 ml/kg/day and increase by 10 gm) ml/kg/day till 120 ml/kg is reached

AGA & LBW



Initiate at 60 ml/kg/day and and increase by 15 th ml/kg/day till 120 ml/kg is reached on the 5 day of PN

Neonates under radiant heaters or on phototx an extra 30ml/kg/day of water

Infants & Older Children

100 – 100 – 120 120 ml/kg 1000ml + 50 ml foe each kg > 10 1500 + 20 for each more than 20

<10 kg 11-20 kg >20 C. Protein Requirement AGE/WT VLBW (≤ 1500 gm) 0 – 12 – 12 months 1 – 8 – 8 yrs 8 yrs and above

Dosage (gm/kg/day) 2.25 2.50 1.50 – 1.50 – 2.0 2.0































P e d i a t r i c

N o t e s | 123

D. Carbohydrate Requiremen R equirementt % dextrose = gram dextrose x 100 Vol infused (ml Shud provide 50 – 50 – 60 60 % 0f total non-protein calories  Requirement ranges frm 10 to 25 gm/kg/day  Infusion shud not exceed 12.5mg/kg/min  Shud b decreased if urinary glucose ≥0.5% (2+) or blood sugar  exceeds 7 mmol/L in neoanate or 9.7 mmol/L I above 1 mo of age E. Fat Requirement AGE Dosage (gm/kg/day) 0 – 12 – 12 months 2 1 – 8 – 8 yrs 4 8 yrs and above 2.5 30 – 30 – 40 40 % of total calories shud b provided as fats  2 – 4% – 4% as EFA  Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till  recommended amt is reached F. Daily Electrolyte Requirements Electrolytes Neonates 1-6 mos 6 mo -11 Adolescents (mmol/kg) (mmol/kg) yr (mmol/kg) (mmol/kg) NaCl 3 – 5 – 5 3 – 4 – 4 3 – 4 – 4 60 – 60 – 100 100 Potassium 2 – 4 – 4 2 – 3 – 3 2 – 3 – 3 80 – 80 – 120 120 Cal gluc 0.6 – 0.6 – 1.0 1.0 0.25 – 0.25 – 1.2 1.2 0.25 – 0.25 – 1.2 1.2 4.7 Phosphate Magnesium



1.0 0.1250.250

(max of 4.7)

(max of 4.7)

1 – 2 – 2

1 – 2 – 2

0.1250.250

0.1250.250

30 – 30 – 45 45 4 – 8 – 8

Calcium gluconate contains 100 mg calcium gluconate or 9 mg elemental calcium/ml































P e d i a t r i c

G.

Trace Elemental Requirements Prematures Trace (ug/kg) Elemental

Infants & Children

N o t e s | 124

Adolescents (mg)

(ug/kg) Zinc 400 100 – 100 – 500 500 2.5 – 2.5 – 4 4 Copper 50 20 0.5 – 0.5 – 1.5 1.5 Chromium 0.3 0.14 – 0.14 – 0.2 0.2 0.01 – 0.01 – 0.04 0.04 Manganese 10 2 – 10 – 10 0.15 – 0.15 – 0.5 0.5 Iodine 8 8 0.2 Selenium 4 4 0.3 Flouride 57 57 0.9 In the absence of available prep of trace elements; weekly blood  transfusion may be given at 20 ml/kg Iron: 2 mg/kg, with dose increased to 6 mg/kg if Fe def is  documntd; provided by adding iron dextran to amino acid soln































P e d i a t r i c

TPN for NEONATES Wt 2kg 1. TFR = 100 ml/kg/day x 2 kg 2. Intralipid 20% 1 g/kg/day x 2kg = 2g/day 2 g = 20g x 100ml

200 ml 10 ml

3. Compute for TFR 1 TFR – Intralipid Intralipid = 200 -10ml = 90 ml TFR1 = TFR – 4. Vamin 7% 1 g/kg/day x 2 kg = 2g = 29 ml 2 g = 7g x 100ml 5. Multivitamins Benutrex c 0.5 ml/100ml 0.5 ml = x 1 ml 100ml 190 ml 6. Ca gluc 10% 2ml/kg/day x 2 kg 4 ml 7. Dextrosity (D10) get d50w TFR 1 x dextrosity factor (0.11) 21 ml 190 x 0.11 8 . D5IMB = TFR 1 – 1 – (Vamin (Vamin + MTV + Ca gluc + D50W) 190 – 190 – (29 (29 + 1+ 4+ 21) = 135 ml 9. IV rate = TFR T FR 1 / 24H 190 ml/ 24H 8 ml/H Order: Start TPN as ff: TFR= 100ml/kg/day D5 IMB 135 ml D50W 21 ml Vamin 7% 29 ml

N o t e s | 125































P e d i a t r i c

N o t e s | 126

Sample Solving: Wt 15 80kcal/kg A. Energy: 15 x 80 = 1, 200 kcal/day B. TFR: 1,250 ml/day CHON: (1gm/day) 15 x 1 C. Prep: Aminosteril 6% (6gms/100ml) (6gms/100ml) 6gms x 15 gms = 250 ml 100 x

D.

CHO: % = gm x 100 Vol Prep: D50W

10% x = 125 gms 1250

50 gm = 125gm 100 ml x

E.

Lipids: ( 1 gm) Prep: 10% Intralipid (10gms/100ml) (10gms/100ml)

15 x 1 =15

10 gms x 15 gm = 150 100 ml x

F.

Sodium: (3 mmol/kg) Prep: 2.5 mmol/ml

15 x 3 = 45 mmol/kg

2.5 mmol x 45 = 18 ml ml x

G.

Potassium: (2 mmol/kg) Prep; 2 mmol/ml

15 x 2 = 30 mmol/kg

2.0mmol x 30 = 15 ml ml x

H.

Calcium gluc: (0.25 mmol/kg) Prep: 10% Cal gluc 0.25 mmol x ml

I.

15 x 0.25 = 3.75

3.75 = 15 ml x

Magnesium: (0.25 mmol/kg) Prep: 25% MgSO4 2 mmol x 3.75 = 1.9 ml x 2 = 4 ml ml x

15 x 0.25 = 3.75

































P e d i a t r i c

J.

Total Mixture: Aminostril D50W Na K Cal gluc MgSO4

24 hrs 250 250 18 15 15 4 ml

12 hrs 125 125 9 7.5 7.5 2 ml

Total

552

276

N o t e s | 127































P e d i a t r i c

EMERGENCY MEDICINE EMERGENCY ET tube Age in years + 4 4 ET diameter x 3 >10 yo cuffed Laryngoscope sizes PT Term 0-6mos 6-24 mos >24 mos

Epinephrine Amiodarone Cardioversion Albumin

Miller 00 or 0 Miller 0 Miller 1 Miller 2 Miller 2 or Mac 2

EMERGENCY MEDS (bradycardia, asystole) (1:1000) 0.1 ml/kg q 3- 5 mins 5 mg/kg rapid IV push 2 J/kg then 4 J/kg then rpt 2x 1gm x wt given in 2-4hrs. Prep: 12.5g/50ml Vol expander: 20ml/kg HypoCHONemia 1gm/k/dose x 4H

N o t e s | 128































P e d i a t r i c

Dopamine

11cc/hr Renal dose Pressor alpha effect

3-5 >5 - <15 >15

N o t e s | 129































P e d i a t r i c

ANAPHYLAXIS Epinephrine (1:1000)

0. 01ml/kg max of 0.5 mg/dose SC < 30 kg 0.15 mg > 30 kg 0.3 mg Diphen = 50mg IM (1mkdose) USN w/ Salbu x 3 doses

O2 SUPPLEMENTATION Peak Flow (6 – (6 – 7 7 yo) (Ht cm – cm – 100) 100) x 5 + 170 female + 175 male Nasopharyngeal catheter catheter = flow rate x 20 + 20 Nasal cannula = flow rate X 4 + 21 TFR= TV x RR x IE ratio + dead space (2000) TV= 10 ml x wt TFR Short cut: wt x 10 + 40 ml divide by 0.5 16.77

N o t e s | 130































P e d i a t r i c

N o t e s | 131

NORMAL VALUES NORMAL VALUES AVERAGE WEIGHT (3,000 grams) 0 – 6 mos Age in months x 600 + BW 7 – 12 mos Age in months x 500 + BW Children 1 – 6 – 6 yo Age in years x 2+ 8 7 – 12 – 12 yo Age in years x 7 – 7 – 5 5 / 2 HEAD CIRCUMFERENCE [35 cm (+ 2cm)] 1 – 4 – 4 Mos ½ inch per month 5 – 12 – 12 mos ¼ inch per month 2 years old 1 inch per year 3 – 5 – 5 yo ½ inch per year 6 – 20 – 20 yo ½ inch inch per per 5 years LENGTH (50 cm) 0 – 3 – 3 mos 9 cm 4 – 6 – 6 8 cm 7 – 9 – 9 5 cm 10 – 10 – 12 12 3cm

(inch = 2.54cm)

































P e d i a t r i c

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

63.7 65.9 67.8 69.5 71.0 72.3 73.6 74.9 76.1 77.2 78.3 79.4 80.4 81.4 82.4 83.3 84.2

62.0 64.1 65.9 67.6 69.1 70.4 71.8 73.1 74.3 75.5 76.7 77.8 78.9 79.9 80.9 81.9 82.9

53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69

3.9 4.1 4.3 4.6 4.8 5.1 5.4 5.7 5.9 6.2 6.5 6.8 7.1 7.4 7.7 8.0 8.3

N o t e s | 132

3.9 4.1 4.3 4.5 4.8 5.0 5.3 5.5 5.8 6.1 6.4 6.7 7.0 7.3 7.5 7.8 8.1































P e d i a t r i c

5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13

109.9 112.6 116.1 118.5 121.7 123.9 127.0 129.1 132.2 134.4 137.5 139.9 143.3 145.8 149.7 152.5 156.5

108.4 111.0 114.6 117.1 120.6 123.0 126.4 128.8 132.2 134.7 138.3 140.9 144.8 144.8 147.6 151.5 154.1 157.1

89 90 91 92 93 94 95 96 97 98 99 100 101 102 103-105 106-108 109-111

12.8 13.0 13.2 13.4 13.7 13.9 14.1 14.4 14.7 14.9 15.2 15.5 101.0 16.1 16.5-17.1 17.4-18.0 18.3-19.0

N o t e s | 133

12.4 12.6 12.8 13.0 13.3 13.5 13.8 14.0 14.3 14.6 14.9 15.2 15.5 15.9 16.2-16.7 17.0-17.6 17.9-18.6

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