ESSENTIAL NEWBORN CARE PROTOCOL [from DOH]
▪ What should be done immediately after birth is to dry the baby because hypothermia can lead to several risks
APGAR SCORE
▪ Delaying the cord clamping to 3 mins after birth (or waiting until the umbilical cord has stopped pulsing) Instead of immediately washing the NB, the baby should be placed on the mother’s chest or abdomen to provide warmth, increase the duration of breastfeeding, and allow the “good bacteria” from the mother’s skin to infiltrate the NB Washing should be delayed until after 6 hours because this exposes the NB to hypothermia and remove vernix. Washing also removes the baby’s crawling reflex.
▪
▪
NEWBORN CARE Umbilical Cord ▪ Cut 8 inches above abdomen after 30 sec
▪ In nursery, cut the umbilical cord 1 ½ inch above the abdomen ▪ Healing should take place around 7 – 10 days Eye Prophylaxis ▪ 1% silver nitrate drops [most effective against Neisseria]
Vaccine ▪ BCG
▪ PT: 0.5 mg ▪ Hep B Newborn Screening ▪ Done on 16th hr of life . can be repeated after 2 weeks ▪ Patients w/ CAH will die 7 – 14 days if not treated ▪ Patient w/ CH will have permanent growth defect and MR if not treated before 4 weeks Disorder Screened
Effects Screened
Congenital Hypothyroidism Congenital Adrenal Hyperplasia (CAH) Galactosemia (Gal)
Severe MR
Effects if Screened & treated Normal
Death
Alive &Normal
Death of Cataract
Alive &Normal
Severe MR Severe Anemia Kernicterus
Normal Normal
Phenylketonuria PKU G6PD
HR Reflex irritability Activity Respiration The APGAR Score 8 – 10 4–7 0–3
BCG DPT OPV/IPV Hep B
Measles MMR Hib Pneumococcal Rotavirus Hep A Varicella
Flu
# of dose 1
Interval
Booster
-
-
3
4 wks
3
4 wks
18 mos 4 – 6 yo Same as DPT
3
6 wks from 1st dose; 8 wks from 2nd dose -
15 mos
1
2, 4, 6 mos
18 mos
6 mos (PCV7) 2 yrs (PPV) 3 and 5 mos
18 mos 2
I month
1 yr and up
2
1st: 12 – 15 mos 2nd: 4 – 6 yo
2
6 – 12 mos apart Bet 1st & 2nd dose: at least 3 mos yearly
6 months
Good cardiopulmonary adaptation Need for resuscitation, esp ventilatory support Need for immediate resuscitation
NEONATAL JAUNDICE
Min age of 1st dose At birth Before 1 mo 6 wks (2, 4, 6 mos) 6 wks 2, 4, 6 mos) At birth (0, 1, 6 mos) EPI (6, 10, 14) 6 – 9 mos
1
>100 Cough Active Good
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, 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) Suction secretion prn Will infrom AP /AP attended delivery
IMMUNIZATION Vaccine
2 All pink
NICU
▪ Erythromycin 0.5% [Chlamydia] ▪ Tetracycline 1% ▪ Povidone iodine 2.5% Vitamin K ▪ 1 mg Vit K1
Color
Evaluates the need for resuscitation Taken 1 and 5 minutes after birth 0 1 Blue, pale Body pink, extremities blue 0 <100 No response Grimace Limp Some flexion Absent Slow, irregular
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 & symptoms: Non-specific Dx: CBC, CXR, blood and urine culture, lumbar tap for CSF studies Treatment: Empiric antibiotics [Ampicillin + 3rd gen Cephalosporin or Aminoglycoside) / Supportive
Risk Factors 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 PHYSIOLOGIC vs PATHOLOGIC FACTORS Onset Rate of inc of TSB Persistent
PHYSIOLOGIC > 24 hrs of life < 0.5mg/dl/hr < 14 days
Total S. Bilirubn
FT: < 12 mg/dl PT: < 14 mg/dl
Signs/Symptoms
ZONE I II III IV V Parameter Onset
Pathophysiology Mngt
PATHOLOGIC < 24 hrs of life > 0.5mg/dl/hr FT: > 8 days PT: > 14 days Any level requiring phototherapy Vomiting, lethargy, poor feeding, excess wt loss, apnea, inc RR, temp instability
KRAMER CLASSIFICATION JAUNDICE Head/neck Upper trunk Lower trunk, thigh Arms, leg, below knee Hands/feet
mg/dl 6–8 9 – 12 12 – 16 15 – 18 > 15
BREAST FEEDING vs BREASTMILK JAUNDICE BREASTFEEDING BREASTMILK 3rd to 5th day Late; start to rise on day 4; may reach of life 20 – 30 mg/dl on day 14 then ↓ slowly Normal by 4 – 12 weeks ↓ milk intake → Unknown; Prob. due to β – glucoronidase in BM which ↑ enterohepatic circulation ↑ enterohepatic Normal LFT; (-) hemolysis circulation Fluid and If breastfeeding is stopped, rapid ↓ in caloric bilirubin level in 48 hrs, if resumed will ↑ supplement to 2 – 4 mg/dl but no precipitating previous events
MILK FORMULAS 1:1 dilution 1:2 dilution Mead-Johnson, Nestle, Glaxo, Wyeth, Abbott, Unilab Dumex, Milupa 0-6 months (20cal/oz) Lactose free (0-6months) Mead-johnson: Alacta , Enfalac Nestle: NAN1, Nestogen Glaxo: Frisolac Dumex: Dulac Abbott: Similac advance Milupa: Alaptamil Wyeth: S26, Bonna Unilab: Mylac 6months onwards (20cal/oz)
Mead-johnson: Enfalac lacto-free Nestle: AL110 Milupa: HN25 Wyeth: S26 Lacto-free
Mead-johnson: Enfapro Nestle: NAN2, Nestogen 2 Glaxo: Frisomil Dumex: Dupro Abbott: Gain Wyeth: Bonnamil. Promil Unilab: Hi-nulac 1 year onwards (20 cal/oz)
Mead-johnson: Enfapro lacto-free
Mead-johnson: Enfagrow, Lactum Nestle: NAN3, Neslac Glaxo: Frisorow Dumex: Dugrow Abbott: Gainplus Wyeth: Progress, Promil Unilab: Enervon bright Hypoallergenic (20cal/oz)
Mead-johnson: Enfaprem Nestle: PreNAN Abbott: Similac prem Milupa: Preaptamil
Mead-johnson: Pregestimil Nestle: Alfare, NAN HA1, NAN HA2
Mead-johnson: Prosoybee Abbott: Isomil Wyeth: Nursoy
Lactose free (6months onwards)
Premature Infant (24cal/oz)
Soy-Based (20cal/oz)
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 TFR1 = TFR – Intralipid = 200 -10ml = 90 ml 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 – (Vamin + MTV + Ca gluc + D50W) 190 – (29 + 1+ 4+ 21) = 135 ml 9. IV rate = TFR 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 Ca Gluc 4 ml MTV 1 ml 190 ml to run at 8 ml/h Intralipid 20% 10 ml to run for 24H
TPN Vamin 9% 0.67 cal/ml Start 0.5 g/k/day inc by 0.5 g until 3 -3.5g/k/day Compute = wt x dose x prep (100/9) Intralipid 10% 20% Start 0.5 g/k/day inc by 0.5 g until 3 g/k/day Compute = wt x dose x prep (100ml/ 10) = ml/24H Amino acids Start 0.5 g/k/day inc by 0.5 g until 3 g/k/day Compute = wt x dose x prep (100ml/g) = ml/24H TPN shortcut computation Wt 10 kg TFR= 100 ml/k/day
TFI = 1000ml/day
Vamin 7% 7 = 2 g/kg x 10kg 100 CaGluc 2ml/kg D5IMB D50W 0.11 x 1000ml
285 ml 20 ml 485 ml 110 ml 1000ml x 37 cc/h TPN (PEDIATRICS) Energy Requirment
AGE/WT Neonates Infants & Older Children <10 kg 11-20 kg >20 AGE/WT Neonates: VLBW (≤ 1500 gm)
Caloric Rquirement 90-120 kcal/kg 10-120 kcal/kg 1000kcal + 50 kcal foe each kg > 10 1500 + 20 for each more than 20 Fluid Requirement Fluid Rquirement Initiate at 40 – 60 ml/kg/day and increase by 10 ml/kg/day till 120 ml/kg is reached
AGA & LBW
Initiate at 60 ml/kg/day and increase by 15 ml/ kg/day till 120 ml/kg is reached on the 5th day of PN Neonates under radiant heaters/on phototx an extra 30ml/kg/day of water Infants & Older Children <10 kg 11-20 kg >20
100 – 120 ml/kg 1000ml + 50 ml foe each kg > 10 1500 + 20 for each more than 20
Protein Requirement AGE/WT Dosage (gm/kg/day) VLBW (≤ 1500 gm) 2.25 0 – 12 months 2.50 1 – 8 yrs 1.50 – 2.0 8 yrs and above 1.00 – 1.50 With the initiation of PB|N, start w/ 0.5gm/kg/day and gradually increased by 0.5gm/kg/day till recommended protein is reached. Carbohydrate Requirement % dextrose = gram dextrose x 100 Vol infused (ml Should provide 50 – 60 % 0f total non-protein calories Requirement ranges frm 10 to 25 gm/kg/day Infusion should not exceed 12.5mg/kg/min Should be 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 Fat Requirement AGE Dosage (gm/kg/day) 0 – 12 months 2 1 – 8 yrs 4 8 yrs and above 2.5 30 – 40 % of total calories shud b provided as fats 2 – 4% as EFA Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till recommended amt is reached Daily Electrolyte Requirements Elect. (mmol/kg)
Neonates
NaCl Potassium Cal gluc
3–5 2–4 0.6 – 1.0
Phosphate Magnesium
1.0 0.125-0.250
1-6 mos
6m-11yrs
3–4 2–3 0.25 – 1.2 (max of 4.7) 1–2 0.125-0.250
3–4 2–3 0.25 – 1.2 (max of 4.7) 1–2 0.125-0.250
Adolescents 60 – 100 80 – 120 4.7 30 – 45 4–8
Calcium gluconate contains 100 mg calcium gluconate or 9mg elemental calcium/ml; 1 gm of Ca gluconate contains 4.7mEq or 2.35 mmol of Ca.
Trace Elemental Requirements
VITAMINS
Trace Elemental
Prematures (ug/kg)
Infants & Children (ug/kg)
Adolescents (mg)
Stimulants Buclizine (syrup)
Zinc Copper Chromium Manganese Iodine Selenium Flouride
400 50 0.3 10 8 4 57
100 – 500 20 0.14 – 0.2 2 – 10 8 4 57
2.5 – 4 0.5 – 1.5 0.01 – 0.04 0.15 – 0.5 0.2 0.3 0.9
w/ Folic acid (Megaloblastic Anemia)
▪ 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 sol’n OSTERIZED FEEDING TFR
Pizotifen (drowsiness) MTV w/ Iron
60 - 70% = 100/feeding q 6H 10 kg x 60% TFR = 600 0.5 g/kg inc q other day by 0.5 , max of 2 g/kg Dose x wt x prep (Vamin 7%, 9%) 0.5 x 10 kg x (100 /7) = 71 g/kg CHON = 71 g/kg If no prep = dose x wt x 4 = 20 g/kg 60% (TFR – CHON) x 0.6 (600- 71) x 0.6 = 317 CHO = 317 181 (the rest are fats , divided into 6 feedings)
CHON
CHO
Fats
w/ Serotonin (for migraine + dec wt)
COMPOSITION OF ORS Na
K
Cl
Glu
Glucolyte
60
20
50
100
Hydrite
90
20
80
111
WHO Pedialyte
75 30 45 90 41
20 20 20 20 11
65 30 35 80
75
ORS
30 45 90
Gatorade Iron Deficiency Anemia
9/100
Supplemental Iron = Therapeutic Dose: 5 - 6 mkday for 3 mos Maintenance Dose: 3 - 4 mkday Elemental iron 20% of FeSo4 12% Fe gluconate 33% Fe fumarate Wt x Dose x Prep Ferlin drops15mg/ml Fe 75 mg Prophylactic dose Term 1 mg/k/Day, start 4 mos-1y PT 2 mkD, start 2 mos-1y Therapeutic dose 3 mkD BID, QID for 4-6mos Ferlin syrup 30mg/ml Fe 149.3 mg Supplemental dose 10-15 mg OD Therapeutic dose 3 mkD TID, QID for 4-6mos Sangobion syr (Fe gluc 250mg elem Fe 30mg) Incremin with Iron Syrup 30 mg elem Fe ASSESSMENT OF DEHYDRATION [CDD]
PARAMETER
NO SIGN
SOME SIGN
SEVERE
Condition
Well, Alert
Restless Irritable
Eyes
Normal
Sunken
Lethargic Unconscious Floppy Very sunken Dry
Tears
Present
Absent
Absent
Mouth/Togue
Moist
Dry
Very dry
Thirst
Drinks normally Not thirsty
Thirsty Drinks eagerly
Skin pinch
Goes back quickly
Goes back slowly
Drinks poorly Not able to drink Goes back very slowly
Severity
▪ ▪
Mosegar Vita 0.25 mg/day prep 0.25 /5 ml Appetens Propan Appebon 2 - 8yo 5 - 10 ml OD 7 - 14yo 10 - 20 ml OD Molvite 7 - 12yo 10 - 15 ml OD 3 - 6yo 5 - 10 ml OD 1 - 2yo 2.5 - 5 ml OD Iberet Ferlin (10 mcg folic acid) Macrobee 1 - 2yo 2.5 - 5 cc OD 3 - 6yo 5 - 10 cc OD 7 - 12yo 10 - 15 cc OD Mosegor vita syr Appetens Propan w/ iron syr (Fe So4; elem fe 30mg) Appebon w/ iron syr (FeSo4; elem fe 10mg) Mosegor vita Mosegor plain Appeten Jagaplex syrup 1-2yo 5ml OD 3-6yo 10 ml OD 7-12yo 15 ml OD Clusivol Power syrup syr 100mg/5ml 2-6yo 5 ml OD 7-12yo 10 ml OD Zeeplus <2yo 2.5 ml OD 2-6yo 5 ml OD 7-12yo 5-10 ml OD Polynerv 1-2yo 2.5 ml OD 3-6yo 5 ml OD 7-12yo 10 ml OD 0-6mo 0.5 ml-1 ml OD 7mo-1yr 1-1.5 ml OD 1-2yrs 1.5-2ml OD FLUID MANAGEMENT Less than 2 yo
More than 2 yo
Mild 50cc/kg 30cc/kg Moderate 100cc/kg 60cc/kg Severe 150cc/kg 90cc/kg To run for 6 – 8 hrs then refer Usual fluid is D5 0.3 NaCl; if however more than 40 kg then D5 LR ORAL REHYDRATION THERAPY AGE Amount ORS to give/loose stool 50 – 100 ml 100 – 200 ml As much as wanted Amount of ORS to give in 1st 24 hrs:Wt (kg) x 75ml/kg
PLAN A
PLAN B
30ml/kg AGE Infants (<1 yo) 1 hr Children (>1 yo) 30 mins In fluid resuscitation: use 20cc/kg as bolus. Usually PLR
PLAN C
70ml/kg 5 hrs 2.5 hrs
MAINTENANCE WATER HOLLIDAY – SEGAR METHOD Weight [kg] Daily Requirement [ml/kg] 3 – 10 100 ml 10 – 20 1000 + 50ml/kg for each kg >10 >20 1500 + 20ml/kg for each kg >20 Maintenance water rate 0 – 10 10 – 20 >20
4ml/kg/hr 40 mk/hr + 2ml/kg/hr x wt 60 mk/hr + 1ml/kg/hr x wt
COMPOSITION OF IV SOLUTION Na K Cl PNSS 154 154 0.45 NaCl 77 77 D5 0.3 NaCl 51 51 D5 LRS 130 4 109 D5 NM 40 13 40 D5 IMB 25 20 22 D5 NR 140 5 98 Na requirement: 2 – 4 meq/k/day K requirement: KIR: 0.2 – 0.3 meq/k/hr ; max 40 meq KIR = Rate x incorporation / wt Fluid
HCO3 Dxt 5 28 5 16 5 23 5 27 5 2 – 3 meq/k/day
CLINICAL FEATURES of PNEUMONIA Bacterial
Fever >38.5C Chest recession Wheeze not a sign of primary bacterial URTI Wheeze Marked recession Fever < 38.5 RR normal or increased
Viral Mycoplasma
School children Cough wheeze CXR in assessing CAP etiology
Alveolar infltrates
Bacterial pneumonia
Interstitial infiltrates Both infiltrates
Viral pneumonia Viral, Bacterial, or Mixed
Microbial causes of CAP according to Age Birth to 20 days
Grp B Strep Gram (-) enterobacteria
3 weeks to 3 months
RSV B. pertussis Parainfluenza virus S. aureus S. pneumonia RSV, Parainfluenza virus H. influenzae Influenza virus, Adeno, Rhinovirus M.tuberculosis S. Pneumonia M.pneumoniae M.pneumoniae S. pneumonia C. Pneumoniae M.tuberculosis
4 months to 4 yo
5 years to 15 years
CMV L. monocytogenesis
Clinical Practice Guidelines in the Evaluation and Management of PCAP Predictors of CAP in patients with cough (3 mos to 5 yrs) – tachypnea &/or chest retractions (5 – 12 yrs) – fever, tachypnea & crackles (>12 yo) – (a) fever, tachypnea & tachycardia; (b) at least 1 AbN CXR WHO Age Specific classification for tachpynea 2 to 12 mos: >50 RR 1 to 5 yrs: >40 RR >5 yrs: >30 RR
THERAPEUTIC MANAGEMENT OF CAP OPD MANAGEMENT Birth to 20 days Admit 3 weeks to 3 months Afebrile: Oral Erythromycin (30-40mkd) Oral Azithromycin (10 mg/kg/day) day 1 5 mkday for day 2 to 5 Admit: febrile or toxic 4 months to 4 yo Oral Amoxicillin (90mkd/3doses) Alternative: Amox-Clav, AZM, Cefaclor Clarithromycin, Erythromycin 5 years to 15 years Oral Erythromycin (30-40mkd) Oral AZM 10mkday day 1, 5mkday day 2-5 Clarithromycin 15mkday/2 doses Pneumococcal infxn: Amoxicillin alone IN-PATIENT MANAGEMENT Birth to 20 days Ampicillin + Gentamicin w or w/o Cefotaxime 3 weeks to 3 months Afebrile: IV Erythromycin (30-40mkd) Febrile: add Cefotaxime 200mkd Cefuroxime 150 mkd 4 months to 4 yo If w/ pneumococcal infection: IV Ampicillin (200mkd) Cefotaxime 200mkd Cefuroxime 150 mkd 5 years to 15 years Cefuroxime 150 mkd + Erythromycin 40mkd IV or orally for 10-14 days If pneumococcal is confirmed: Ampicillin 200mkd VARIABLE
A (Min Risk)
PCAP B (Low Risk)
C (Mod Risk)
D (High Risk)
Comorbid Illness
None
Present
Present
Present
Compliant caregiver
Yes
Yes
No
No
Possible
Possible
Not
Not
None Able >11 mos
Mild Able >11 mos
Moderate Unable <11 mos
Severe Unable <11 mos
>50/min >40/min >30/min
>50/min >40/min >30/min
>60/min >50/min >35/min
>70/min >50/min >35/min
Ability to follow up DHN Feeding Age RR 2 – 12 m 1 – 5 yo >5 yo
PCAP A/PCAP B No diagnostic usually requested PCAP C/PCAP D The ff shud b routinely requested CXR APL (patchy – viral; consolidated – bacterial) WBC C/S (blood, Pleural Fluid, tracheal aspirate on initial intubation) Blood gas/Pulse oximeter The ff may be requested: C/S sputum The ff shud NOT be routinely requested: ESR & CRP Antibiotic Recommendation PCAP A/PCAP B and is beyond 2 yo & having fever w/o wheeze PCAP C and is beyond 2 yo, having high grade fever, having alveolar consolidation on CXR, having WBC >15,000 PCAP D – refer to specialist Antibiotic Recommendation PCAP A/PCAP B w/o previous antibiotic Amoxicillin (40 – 50 mkday) TID PCAP C – Pen G IV (100,000 IU/k/d) QID PCAP C who had no HiB immunization Ampicillin IV (100mkd) QID PCAP D – refer to specialist What should be done if px is not responding to current antibiotics? If PCAP A/PCAP B not responding w/n 72 hrs Change initial antibiotic Start oral Macrolide Reevaluate dx PCAP C no responding w/n 72 hrs consult w/ specialisr PCN resistant S pneumonia Complication Other dx PCAP D not responding w/n 72hrs, then immediate consultto a specialist is warranted Switch from IV to Oral Antibiotic done in 2 – 3 days after initiation in px who: Respond to initial antibiotic Is able to feed with intact GI tract Does not have any pulmo or extra pulmo complication Ancillary Treatments O2 and Hydration Bronchodilators, CPT, steam inhalation and Nebulization Prevention Vaccines Zinc Supplementation (10mg for infants / 20mg for children > 2 yo) Signs of Respiratory Failure VARIABLE
A (Min Risk)
B (Low Risk)
C (Mod Risk)
D (High Risk)
Retractions
-
-
Head bobbing Cyanosis Grunting Apnea Sensorium
-
-
Subcostal/ Intercostal +
Subcostal/ Intercostal +
None
Awake
+ Irritable
+ + + Lethargy / Stupor Coma/
None
None
Present
Present
OPD f/u at end of tx
OPD f/u after 3 days
Admit to regulat ward
Admit to CCU; Refer to specialist
Comp: Effusion Pneumo -thorax Action Plan
BRONCHIOLITIS Acute inflammation of the small airways in children <2 yrs Most commonly caused by RSV Related to exposure to cigarette smoke Risk factors for severe dse: <6 mos Heart or lung disease Prematurity Immunodeficiency Signs/Symptoms low grade fever, rhinorrhea, cough, wheezing hyperresonance to percussion CXR: hyperinflation, interstitial infiltrates Treatment Mild [at home]: Increased fluids, trial of inhaled bronchodilators, aerosolized epinephrine Severe: Admit to hospital if: Marked respratory distress; Poor feeding; O2 sat <92%; hx of prematurity < 34 wks; underlying cardiopulmonary dse; unreliable caregivers Manage with ventilatory and O2 support, hydration, inhaled bronchodilators and ribavirin
SEVERITY OF ASTHMA EXACERBATION VIRAL CROUP vs EPIGLOTTITIS VIRAL CROUP Age group 3 mos to 3 yrs Stridor 88% Pathogen Parainfluenza virus Onset Prodrome (1 – 7 days) Fever Severity Low grade Associated symptom Barking cough, hoarseness Respond to racemic Stridor improves epinephrine CXR “steeple sign”
EPIGLOTTITIS 3 – 7 yrs 8% H. influenzae type B Rapid (4 – 12 hrs) High grade Muffled voice, Droolong None
Breathless
MODERATE
SEVERE
Walking
Talking Infant –softer shorter cry Difficult feeding
At rest Infant stops feeding
BRONCHIAL ASTHMA
Talks in
Sentences
Prefers sitting Phrases
Hunched Words
Alertness
May be agitated
Usually agitated
Usually agitated
Inc
>30/min
Usually
Usually
MANAGEMENT APPROACH BASED ON CONTROL Step 2 Step 3 Step 4
RR
Inc <60/min <50/min <40/min <30/min Usually not
Wheeze
Moderate
Loud
Usually loud
Paradoxical Thoracoabd movt Absence of wheeze
Pulse Rat Normal PR 2-12 mo 1-2 y 2-8 y Pulsus paradoxus
<100
100-200
>120
Bradycardia
<10mmHg
Maybe present 10-25mmHg
Present 20-40 mmHg
Absence suggests resp ms fatigue
>80%
60-80%
<60%
<160/min <120/min <110/min Absent
PEF
Asthma education and Environmental control As needed rapid acting B2 agonist
PRN B2 Agonist
C O N T R O L L E R
Step 5
Select 1
Select 1
Add 1 or more
Add 1 or more
Low dose ICS
Low dose ICS + LABA
Oral steroids
Leukotriene modifier
Medium or Hi dose ICS Low dose ICS + Leukotriene Modifier Low dose ICS + Salbutamol Release theophylline
Med to Hi dose ICS + LABA Leukotriene Modifier Sustained Release theophylline
Anti-IgE treatment
LEVELS OF ASTHMA CONTROL [GINA GUIDELINES] CONTROLLED
PARTLY
None [2x or less/week]
More than 2x a week
Limitation of activities
None
Any
Nocturnal sx/ awakening
None
Any
Need for reliever/ recue tx
None
More than 2x a week
Lung function (PEF OR FEV1)
Normal
80% predicted
Exacerbation
None
One or more/ yr
Daytime symptom
UNCONTROLLED
Three or more features of partly controled asthma present in any week
One in any week
Drowsy or confused
Normal RR <2 mo 2-12 mo 1-2 y 2-8 y Accessory ms
PaO2
Normal
>60 mmHg
<60 mmHg
PaCO2
<45 mmHg
<45 mmHg
>45 mmHg
O2 Sat
>95%
91-95%
<90%
ATOPIC DERMATITIS
Step 1
RESPIRATORY ARREST IMMINENT
Can lie
“thumbprint sign”
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) D5 0.3 NaCl 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 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses Incorporate Budesonide 10 mkd LD (max 200mg IV); then 5mkd q6h IV (max of 100 mg IV) Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, refer for desaturations <95% Will inform AP Pls inform Dr _____ of this admission Thank you.
MILD
▪ ▪ ▪ ▪ ▪
Hereditary, AR
▪ ▪ ▪ ▪ ▪
hx of Asthma thickened, shiny, red exacerbated by dry skin, contact sty, & anxiety tx:hydrocortisone or fluocinolone moisturizer
SEBORRHEIC DERMATITS
CONTACT DERMATITIS
▪
▪ ▪ cloxa/cefalexin if with
Irritant – strong chem.
▪ excessive
e.g. diaper rash remove reactant Allergic e.g. cosmetic, perfume tx: high/mod potency steroid
infxn
▪ ▪ ▪
sebum accumulation on scalp, face, midchest, perineum greasy scalp (cradle cap) physiologic for 1st 6mos tx: ↓ potency steroid
HYPERSENSITIVITY REACTION Please admit under the service of Dr. __________________ TPR q4H and record Hypoallergenic diet Labs: CBC U/A (MSCC) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: *Epinephrine (1:1000) 0.1mg/kg/dose IM anterolateral thigh (max of 0.3 mg) *Salbutamol neb x 3 doses q 20 mins Diphenhydramine 10 mkdose LD (max of 200mg IV); thenmg IV) 5mkdose q6h IV (max of 100 Ranitidine IVTT at 1mkdose q 12h SO: MIO q shift and record Monitor VS q2h and record to include BP Continue TSB for fever O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations <95% Will inform AP Pls inform Dr _____ of this admission Thank you.
ANAPHYLAXIS A syndrome involving a rapid & generalized immunologically mediated rxn After exposure to foreign allergens in previously sensitized individuals A true emergency when cardio and respi system are involved ED Management ▪ O2
▪ ▪ ▪ ▪ ▪ ▪ ▪
Aqueous Epinephrine 1:1000 IM (0.01ml/kg with 0.5ml max) Prepare intubation if w/ stridor & if initial therapy of epi is not effective Continuous monitor ECG and O2 sat & establish IV access Antihistamine to prevent progression H1 & H2 blocker Diphenhydramine (1mg/kg) IM
Steroids may modify late phase or recurrent reaction (Hydrocortisone 5mg/kg/dose) ▪ Epinephrine 1:10,000 IV (0.1ml/kg; 10ml max) ▪ Epinephrine drip (0.01ml/kg/min) Indication for Admission ▪ Persistent bronchospasm
▪ Hypotension requiring vasopressors ▪ Significant hypoxia ▪ Patient resides some distance from a hospital facility SEIZURE BENIGN FEBRILE SEIZURE CRITERIA
▪ ▪ ▪ ▪ ▪ ▪
6 mos – 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 % of BFS develop epilepsy ▪ 25% recurrence of seizure
HYPOVOLEMIC
CARDIOGENIC
DISTRIBUTIVE
/
SHOCK CO is primarily maintained by changes in HR Pump empty Truma, hemorrhage, DHN (diarrhea/ vomiting) Metabolic dse (DM) Excessive sweating Weak/sick pump CHF, cardiomegaly, drug intoxication, hypothermia, after cardiac surgery Sepsis Anaphylaxis Barbiturate intox CNS injury (SCI) SIGNS OF SHOCK
EARLY Narrowed pulse pressure Orthostatic changes Delayed capillary filling Tachycardia Hyperventilation ED MNGT
Duration Recurrence
Simple
Complex
GTC
Focal then gen post ictal
< 15 min
> 15 min or may go into status Recurrent (w/in 24H)
None
CNS exam
Normal
Abnormal
Sequelae
None
Neurodev abnormalities
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 (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 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 SO: MIO q shift and record Monitor VS q2h and record Monitor neurovital signs q4h and record Continue TSB for fever Seizure precaution at bedside as ff: Suction machine at bedside O2 with functional gauge; if with active sz give O2 at 2lpm via NC Diazepam IVTT (0.3 mkd max of 5 mg IV) prn for seizure Will inform AP Pls inform Dr _____ of this admission Thank you. BELLS PALSY
▪ Acute unilateral facial nerve palsy that is not associated with other cranial neuropathies or brainstem dysfunction
Seizure – paroxysmal, time limited change in motor activity and/or behavior that results from abnormal electrical activity in the brain Epilepsy – present when 2 or more unprovoked seizure/s occur at an interval greater than 24 hrs apart
CO = HR x SV
SEIZURE Type
MC in infant &children Normal BV of children 80ml/kg
Compromise CO
Redistribution of fluid w/n vascular space
LATE Decrease systolic pressure Decrease diastolic pressure Cold, pale skin Altered mental state Diaphoresis Decrease urine output
Position Oxygen & Assisted ventilation Intravenous access & Fluid (isotonic crystalloid) Reassess (look for improvement in VS, skin signs, mental status; insert foley cath & monitor UO) Inotropes – help stabilize BP Epinephrine - (0.1 – 1 ug/kg/min) - Infusion of choice for Hypotensive pxs Dobutamine - (5 – 20 ug/kg/min) Cardiogenic shock but not severely hypotensive Dopamine – [(5 – 20 ug/kg/min αconstrictor effect) [(10 – 15 ug/kg/min] Distributive shock after successful fluid resuscitation Cardiogenic shock Diuretic – pxs may get worse after fluid challenge Adenosine / synchronize cardioversion – SVT Defibrillation – Venticular fibrillation
▪ Usually develops abruptly about 2 wks after SVI [EBV, HSV, mumps] ▪ Upper and lower portions of the face are paretic; corner of the mouth drops; unable to close the eye on the involved side
▪ Protection of cornea with methylcellulose eye drops or an ocular lubricant; excellent prognosis CEREBRAL PALSY Non-progressive disorder of posture & movement often associated with epilepsy & abnormalities of speech, vision & intellect resulting from defect or lesion of the developing brain Etiology: infections, toxins, metabolic, ischemia Classifications Physiologic Topogrphic [major motor abnormality] [involved extremities] Spastic Monoplegia [1 side/portion] Athetoid –worm like Paraplegia Rigid Hemiplegia Ataxic Triplegia [3 limbs] Tremor Quadriplegia [all] Atonic Diplegia [LE/UE] Mixed Double hemiplegia unclassified Clinical Manifestations Spastic Arms > legs hemiplegia Dificulty in hand manipulation obviously by 1 yo Delayed walking or walk on tiptoes Spasticity apparent esp. in ankles Seizure & cognitivr impairment Spastic diplegia Bilateral spasticity of the legs Commando crawl Increased DTRs & (+) Babinski sign Normal intellect Spastic Most severe form, due to marked motor impairment quadriplegia of all extremities & high association with MR & seizures Swallowing difficulties Management Baseline EEG & cranial CT scan Hearing & visual function tests Multidisciplinary approach in the assessment & treatment For tight heel cord: tenotomy of the Achilles tendon CSF PATHWAY Choroid plexus (lateral ventricle) → Foramen of Monroe → 3 rd ventricle → Aqueduct of sylvius → 4th ventricle →Foramina of Luschka (2 laterals) → & Magendie (median) → SAS → Absorbed in the arachnoid villi, then in the Venous System
HYDROCEPHALUS Result from impaired circulation & absorption of CSF or from inceased production Obstructive or Noncommunicating ▪ Due to obstruction w/n ventricular system ▪ Abnormality of the aqueduct or a lesion in the 4th venticle (aqueductal stenosis) Non-obstructive or Communicating ▪ Obliteration of the subarachnoid cisterns or malfunction of the arachnoid villi ▪ Follows SAH that obliterates arachnoid villi; leukemic infiltrates Clinical Manifestations ▪ 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 suprapineal recess on the tectum [setting – sun sign] ▪ Long – 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
▪ Extracranial shunt ▪ Acetazolamide & Furosemide [provide temporary relief by reducing the rate of CSF production] MOTOR Full resistance with gravity Some resistance with gravity Movement with gravity Movement w/o gravity Flicker No movement
Very brisk Brisker than average Normal Diminished No response
▪ ▪ ▪ ▪ ▪
Extend across midline
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Occur 1-2 % cases
Edema disappears w/in 1st few days of life Molding and overriding of parietal bones-frequent Disappear during 1st wks of life
No specific tx Cephalhematoma ▪ Subperiosteal hemorrhage; limited to1 cranial bone No discoloration of overlying scalp Swelling not visible for several hours after birth (blding slow process) Firm tense mass with palpable rim localized over 1 area of skull Resorbed w/in 2wk- 3mos and calcify by end of 2nd wk Few remain for years 10-25% cases underlying linear skull fracture No tx but phototherapy in hyperbilirubinemia
Pre Lumbar Tap NPO RBS by gluco prior to lumbar tap Prepare lumbar tap set ▪ 2% Lidocaine # 1 ▪ sterile bottles # 3 ▪ G 23 spinal needle ▪ sterile gloves # 2 ▪ Mannitol 250 cc 1 bot - do not open ▪ Sterile gauze # 1 ▪ Solvent ▪ Sterile gauze w/ Betadine #1 ▪ Diazepam 1 amp ▪ Sterile towel w/ hole #1
▪ 3 cc syringe #2 ▪ 2 manometers
DEEP TENDON REFLEXES 5/5 4/5 3/5 2/5 1/5 0/5
CRANIUM Caput succedaneum ▪ Diffuse edematous swelling of soft tissues of scalp
+4 +3 +2 +1 0
▪ Sterile clamp #1 ▪ 3-way stopcock #1 Post Lumbar Tap
NPO x 4H; Flat on bed Monitor NVS to include BP q 30mins x 4H, then qH CSF exams Bottle # 1 – Gm stain, AFB, India ink, KOH Bottle # 2 – Cell count, CHON, Sugar Bottle # 3 – C/S, save remaining specimen Watch out for vomiting, HA and hypotension
Contraindications to LP
▪ Evidence of Inc ICP ▪ Severe CP compromise ▪ Skin infection at site of puncture DIAZEPAM
MIDAZOLAM
PHENOBARBITAL
ANTICONVULSANTS 0.2 – 0.3 mkdose Drip: 1amp in 50cc D5 W 10mg/amp 0.15 mkdose prn 2 – 3 mins interval IV (1, 5mg/ml) 6 mos - 5 yo 0.05 - 0.10 max of 0.6 mg/kg 6 yo - 12 yo 0.25 - 0.05 max of 0.4 mg/kg >12 yo 0.50 - 2 mg/dose over 2 mins LD: 15 – 20 mkd MD: 5 mkdose q 12h (max load 20 mkday IV Tabs: 15, 30, 60, 90, 100 mg Caps: 16 mg ELIXIR 20mg/5ml Inj: 30, 60, 65, 130 mg/ml MD: PO/ IV Neonate: 3 - 5 mkD QID/ BID Infant/child: 5 - 6 mkD 1 - 5 yo: 6 - 8 mkD 6 - 12 yo: 4 - 6 mkD > 12 yo: 1 - 3 mkD Hyperbil < 12 yo: 3 - 8 mkD BID/TID
PHENYTOIN
Dilantin
LD: 15 – 20 mg/kg/IV MD: Neonate: 5 mkD PO/ IV BID Infant/child: 5 7mkD BID/ TID 6mos – 3y: 8 – 10 mkD 4 – 6y: 7.5 – 9 mkD 7 – 9y: 7 – 8 mkD 10 – 16 y: 6 – 7 mkD Tab: 50mg 100mg TID Extended release caps 30, 100, 200, 300 mg OD, BID Inj: 50 mg/ml
Tegretol
< 6 yo 6 - 12 yo > 12 y
CARBAMAZEPINE Tab 200mg, 100mg XR 100mg, 200mg, Susp 100mg/ 5ml (QID) Initial Increment 10 - 20 mkD BID /TID q wkly til 35 mkD 10 mkD BID 100 mg/ 24H at 1 wk interval 200 mg BID 200 mg/ 24H at 1 wk interval
OXCARBAMAZEPINE
Trileptal VALPROIC ACID
Depakene Depacon TOPIRAMATE
Topamax
chew 400mg Maintenance 20 - 30 mkD BID/ QID 800 - 1200 mg/24H BID/ QID
(8 - 10 mkd BID) Initial: 8 -10 mkD PO BID then Increment: increase over 2 week pd to Maintenance doses: 20 -29 kg: 900 mg/24H PO BID 29.1 -39 kg: 1200 mg/24H PO BID >39 kg: 1800 mg/24H PO BID Tab 150 mg 300mg 600 mg Susp 300mg/5ml PO: Initial : 10 - 15 mkD OD - TID Increment: 10 mkD at wkly interval BID Maintenance: 30 - 60 mkD BID/TID IV: same dose as PO q 6H Rectal : (syrup mix with water 1:1) LD: 20 mkd MD: 10 -15mkd TID Tab 250 mg Syr 250mg/5ml IV 100mg/ml 2 - 16 yo Initial: 1 - 3 mkd PO q HS x 7 days then Increment: Increase by 1 - 3 mkday for 1 - 2 wks then Maintenance: 5 -9 mkD BID Caps: 15 mg, 25 mg Tabs: 25, 50, 100, 200mg
Glasgow Coma Scale Activity Eye Opening Spontaneous To speech To pain None Verbal Oriented Confused Inappropriate words Inappropriate sounds None Motor Follows command Localizes pain Withdraws to pain Abnormal flexion Abnormal extension None
GCS for Infants Activity 4 3 2 1
Spontaneous To speech To pain None
4 3 2 1
5 4 3 2 1
Coos, babbles Irritable Cries to pain Moans to pain None
5 4 3 2 1
6 5 4 3 2 1
N spontaneous movt Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None
6 5 4 3 2 1
CSF ANALYSIS Diff ct
Color
RBC
WBC
Sugar
CHON
Infant (Term)
Xantho
0100
0 -32
Infant (Preterm)
Clear
0100
0 -15
Older child
Clear
0
0 -10
Viral Meningitis
Clear
0
0 -20
TB/Fungal
Clear
0
20 500
L 100 % L 100 % L 100 % L 100 % L> N
70 to 80%
60 150
70 to 80%
60 200
> 50%
10 - 20
40 to 60%
40 - 60
< 40%
> 100 g%
Bacterial Meningitis
Purulent
0
> 1000
N> L
< 50%
> 100 g%
Partially tx BM
Clear
0
100
L> N
> 50%
Dec
ROSEOLA [HSV 6] Exanthem subitum Age of onset < 3 yo with peak at 6 – 15 months High grade fever for 3 – 5 days but behave normally Rash Appears 12 – 24 hrs of fever resolution fades in 1 – 3 days HERPANGINA [Coxsackie A] Sudden onset of fever with vomiting Small vesicles & ulcers w/ red ring found in anterior tonsillar pillars, may also seen on the soft palate, uvula & pharyngeal wall VARICELLA [HSV] MOT Direct contact IP 14 days Prd of comm 1 – 2 days before the onset of the rash until 5 – 6 days after onset & all the lesions have crusted Rash Start from the trunk then spread to othe parts of the body All stages present; pruritic Macule/papule → vesicle →crust Complication Secondary bacterial infection Reye syndrome Encephalitis or meningitis GN Pneumonia Congenital 6 -12 wks AOG: maximal interruption w/ limb devt Varicella with cicatrix(ski lesion w/ zigzag scarring) 16 – 20 wks: eye and brain involvement Tx Acyclovir 15 – 30 mg/kg/day IV or 200 – 400 mg tab q 4hrs minus midnight dose x 5 days: ↑ risk of severity Post exposure VZIg 1 dose up to 96 hrs after exposure prophylaxis Dose: 125 U/10 kg (max 625 U) IM NB whos mother develop varicella 5 days before to 2 days after delivery shud recv 1 vial Vaccine Susceptible children >1 yo w/n 72 hrs ERYTHEMA INFECTIOSUM [Parvovirus B 19] FIFTH DISEASE MOT Droplet spread & blood & blood products IP 16 – 17 Days average Prodrome Low grade fever, headache, URTI Rash Erythematous facial flushing “slapped cheek” and spreads rapidly to the trunk & proximal extremities as a diffuse macular erythema; palms & soles spared Resolves w/o desquamation but tend to wax and wane in 1 – 3 wks
VIRAL INFECTIONS MEASLES (Rubeola) [Paramyxoviridae] MOT Droplet spray IP 10 – 12 days Prd of comm 4 days before & 4 days after onset of rash Enanthem Koplik spots (opposite lower molars) Prodrome High grade fever, conjunctivitis, catharr (3 – 5 days) Rash Appear during height of fever Cephalocaudal[1st along hairline, face, chest] [+] brawny desquamation – disappear w/n 7 – 10 days Complication Otitis media Diarrhea Pneumonia Exacerbation of M tb infection Encephalitis Vit A SD 100,000 IU orally for 6 mos – 1 yo / 200,000 IU >1 yo Tx Post exposure Ig w/n 6 days of exposure prophylaxis (0.25ml/kg max 15 ml) IM Vaccine Susceptible children >1 yo w/n 72 hrs SSPE Chronic condition due to persistent measles infxn Rare but found in 6 mo to >30 yrs of age Subtle change in behavior & deterioration o schoolwork followed by bizarre behavior Elevated titers of Ab to measles virus(IgG, IgM) Inosiplex (100mg/kg/day) may prolong survival GERMAN OR 3 DAY MEASLES [RUBELLA] [Togaviridae] MOT Oral Droplet; transplacentally to fetus IP 14 – 21 days Prd of comm 7 days before &7 days after onset of rash Enanthem Forchheimer spots [soft palate] just b4 onset of rash Rash Cephalocaudal Charac. sign Retroauricular, posterior cervical & postoccipital LAD [24 hrs before rash & remains for 1 wk] Vit A SD 100,000 IU orally for 6 mo –1 y / 200,000 IU >1 yo Tx Post exposure Immunoglobulin [not routine] prophylaxis Considered if termination of preg is not an option 0.55ml/kg) IM Vaccine w/n 72 hrs of exposure Congenital Greatest during 1st trimester; IUGR Rubella Congenital cataract, microcephaly, PDA, “blueberry muffin” skin lesions Congenital or profound SNHL | Motor/mental retardation
MOT IP Period of communicability Prodrome Parotid gland swelling Complications
Hx of Absorbed TT Unknown or <3 >
MUMPS [Paramyxoviridae] Direct contact, airborne droplets, fomites contaminated by saliva 16 – 18 days 1 – 2 days before onset of parotid swelling until 5 days after the onset of swelling Fever, neck muscle pain, headache, malaise Peak in 1 – 3 days 1st in the space between posterior border of mandible & mastoid then extends being limited above zygoma Meningoenephalitis - most frequent, 10 days; M>F Orchitis & Epididymitis Oophoritis Dacryoadenitis or optic neuritis Clean minor Wound
All other Wounds
Td
TIG
Td
TIG
Yes
No
Yes
Yes
No
No
No
No
< 7 yo Dtap is recommended > 7 yo Td is recommended If ony 3 doses of TT received, a 4th dose should be given Give TT (clean minor wounds) if > 10 y since last dose All other wounds (punctured wds, avulsions, burn) Give TT (all clean wounds) if > 5 yrs since last dose VERORAB BERIRAB
Ig (Human) Equine
RABIES VACCINE 0.5 cc/amp; 1 amp IM Day: 0 3 7 14 and 28 RD: 20 iu/kg 300 iu/vial 1 vial = 2ml ½ at wound site ½ deep IM Reqd amt in IU: wt x RD (20IU) Amount in ml = wt x RD (20) x 2 300 20 iu/kg Bayrab 300 iu/2ml | Berirab 300 iu/2ml 40 iu/kg Favirab 200 – 400 iu/5ml 1000 – 2000 iu/5ml
BCG DPT OPV IPV MMR, Measles Varicella Hep B Hep A Hib Typ Pneumococcal Influenza
VACCINES Live attenuated M bovis Diptheria and TT – inactivated B pertussis Sabin trivalent live attenuated virus Salk inactivated virus Live attenuated virus Recombinant DNA, plasma derived Inactivated virus Capsular polysacc linked to carrier CHON Live typhoid vaccine – 3 doses x 2 days IMSC – Vi antigen typ vaccine Capsular polysaccharide 0.5 ml SC /IM – 23 valent purified cap Polysacc Antigen of 23 serotyp Split or whole virus IM 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 U/A (MSCC) IVF: D5 0.3 NaCl 1P/1L (<40 kg) at 3 – 5 cc/kg D5LR 1L (>40 kg) at 3 – 5 cc/kg Medications: Paracetamol prn q4h for T > 37.8°C Omeprazole 1mkdose max 40 mg IVTT OD SO: MIO q shift and record Monitor VS q2h and record, to include BP Continue TSB for fever Refer for Hypotension, narrow pulse pressure (< 20mmHg) Refer for signs of active bleeding like epistaxis, gum bleeding, melena, coffee ground vomitus Will inform AP Pls inform Dr _____ of this admission Thank you.
DENGUE HEMORRHAGIC FEVER Serotype 1, 2, 3, & 4 Aedes egypti IP: 4 – 6 days (min 3 days; max 10 days) DHF SEVERITY GRADING GRADE MANIFESTATION I Fever, non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain (+) Torniquet test II Grade I + spontaneous bleeding; mucocutaneous, GI III Grade II w/ more severe bleeding + Evidence of circulatory failure: violaceous, cold & clammy skin, restless, weak to imperceptible pulses, narrowing of pulse pressure to < 20mmHg to actualHPON IV Grade III but shock is usually refractory or irreversible and assoc w/ massive bleeding CRITERIA FOR CLINICAL DX (WHO) DHF DSS Fever, acute onset, high, lasting 2 – 7 Above criteria days Plus Hemorrhagic manif: Hypotension or narrow pulse (+) Torniquet test pressure [SBP – DBP] Minor & Major bleeding <20mmHg phenomenon Thrombocytopenia <100,000/mm3 Dengue Drips Furosemide drip Dose: 0.04 - 0.5 80 mg + 32 cc Wt x dose = rate (cc/h) 2 Furo drip = 0.1 - 0.5mg/k/hr Prep: 20mg/2ml (2mg/ml) Rate: (wt x dose)/2 = cc/hr ex. 14.5kg x 0.45 = 3.2cc/hr To order: 8ml Furo + 32ml D5W +40 cc to run at 3.2cc/hr
RHEUMATIC HEART DISEASE JONES CRITERIA Precedex drip Dose: 0.2 - 0.7 1ml + 99cc D5W to run at cc/h Wt x dose = rate (cc/h) Noradrenaline (Levophed) 1mg/ml dose :(0.5 – 1 ml/kg) Wt x dose ( each ml contains 4 mcg Noradrenaline) 4 mcg ( for acute hypotension) 2ml + 500cc D5W x 2cc/H (0.5 cc/H) Dopamine ( 5 -20 mcg/kg/min) 200 mg/250ml Single strength 400 mg/250ml DS (div by 2) Wt x dose x 0.075 Dobutamine 250 mg/5ml SS 500 mg/250ml DS(div by 2) Wt x dose x 0.06 Terbutaline Bricanyl SC Inj: 1 mg/ml < 12y – 0.005 – 0.01 mkd x 3 doses q 15 -20 min then q2-6H > 12y – 0.25 mkd Terbutaline drip LD: 2 – 10 mcg/kg then 0.1 – 0.4 mcg/kg/min Ketamine (Ketalar) 10, 50, 100 mg/ml PO: 5mg/kg x 1 IV 0.25 - 0.5 mg/kg IM 1.5 - 2 mg/kg x 1 Morphine IV 0.1 – 0.2 mkd q2-4H prn Naproxen
250, 375, 500mg tab 125mg/5ml > 2yo – 5-7 mkd TID, BID PO
INFECTIVE ENDOCARDITIS DUKE CRITERIA Major Manifestation Minor manifestation Diagnosis Highly probable: 2 major OR 1 major and 2 minor manifestation
Major Manifestations Arthritis (70%) Carditis (50%) Tachycardia Pericarditis Heart murmur of valvulitis Cardiomegaly Signs of CHF [gallop rhythm, distant heart sounds, cardiomegaly] Erythema marginatum (10%) Subcutaneous nodules (2 – 10%) Sydenham’s chorea (15%) Minor manifestations Arthralgia Fever at least 38.8°C
↑ Acute Phase Reactants (CRP & ESR) Prolonged PR interval on the ECG
Diagnosis: Highly probable : 2 major OR 1 major and 2 minor manifestation ACUTE GASTROENTERITIS 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 (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 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) Drops 10mg/ml 1ml OD (<6 mos) | 1ml BID (6 mos – 2 yo) Syrup 20 mg/5ml (>2 yo) 5ml OD Ranitidine IVTT at 1mkdose (if with abdominal pain) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Chart character, frequency and amount of GI losses and replace w/ PLR 1L/1P vol/vol Will inform AP Pls inform Dr _____ of this admission Thank you.
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 (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 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses then refer NaCl (Muconase) nasal spray, 2 sprays per nostrils, then suction using bulb QID Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations <95% Will inform AP Pls inform Dr _____ of this admission Thank you. HENOCH – SCHONLEIN PURPURA [HSP] Most common cause of nonthrombocytopenic purpura in children Typically follows URTI 2 – 8 years old Hallmark Rash – palpable petechia or purpura, evolve from red to brown; last from 3 – 10 days [LE and buttocks] Arthritis of knees and ankles Intermittent abdominal pain due to edema & damage to the vasculatue of the GIT Mngt Symptomatic Steroid for severe abdominal pain
ACUTE GLOMERULONEPHRITIS Inflamm. process affecting the kidney, lesions predominate in glomerulus Etiology: Infections: Bacterial: Grp A β hemolytic strep, S viridans, S pneumo, S. aureus, S epidermidis, S typhi , T pallidum, Leptospira Viral: HBV, Mumps, Measles, CMV, Enterovirus Parasitic: Toxoplasm, Malaria, Schistosoma Drugs: Toxins, Antisera, Vaccines (DPT) Miscellaneous: Tumor Ag, Thyroglobulin GABS Nephritogenic Strains Sites: URT - pharyngitis - M1 2 4 12 18 25 Skin pyoderma - M49 55 57 60 Pathophysio – Immune complex disease Clinical & Lab ▪ Hematuria ▪ Hypocomplementenemia
▪ Proteinuria ▪ Edema ▪ HPN 82%
JUVENILE RHEUMATOID ARTHRITIS [JRA] Criteria
Clinical Manifestations
Mngt
Age of onset <16 yo Arthritis (swelling or effusion) or presence of 2 or more of: ▪ limitation of range of motion, tenderness or pain on motion ▪ increased heat in one or more joints. Duration: 6 wks or longer Onset type defined in the 1st 6mos Polyarthritis: (5 or more inflamed joints) Oligoarthritis (<5) Systemic arthritis w/ characteristic fever Morning stiffness, ease of fatigue esp. after school in the early afternoon, joint pain later in the day, joint swelling Pauci: LE, assoc w/ chronic uvietis Poly: both large & small joints more severe if extensors of elbow and Achilles tendon are involved Systemic: quotidian fever w/ daily temp spikes of 39°C for 2 wks; faint red macular rash over the trunk & proximal extremities NSAIDS then Methotrexate Seroid for overwhelming systemic illness SYSTEMIC LUPUS ERYTHEMATOSUS [SLE]
Criteria
Dx
Mngt
Malar rash Renal disorder Discoid rash Neurologic disorder Photosensitivity Hematologic disorder Oral ulcers (painless) Immunologic disorder Nonerosive arthritis (2 or more joints) ANA abormal titer Serositis (pleuritis, serous pericarditis, Libman sacks endocarditis) Presence of 4 of 11 criteria [ANA not required dx] (+) ANA – screening Anti ds DNA – more specific; reflects the degree of disease activity Decrease C3, C4 in active dse Anti Sm Ab (most specific) NSAIDS use w/ caution Prednisone (1 – 2 mkday) Severely ill: pulse IV steroid (30mkdose) max 1 gm over 60 mins OD x 3 days Severe dse: Pulse IV Cyclophosphamide to maintain renal fxn & prevent progression
Computation for OFI (AGN & limiting OFI) BSA x 400 + UO – IVF (half if w/ Furo) = OFI (then divide to 3 shifts) 20cc x wt x UO – IVF BILIRUBIN METABOLISM
▪ Oliguria ▪ Nausea and Vomiting ▪ Dull lumbar pain
Typical course Latent: few days – 3wks Diuretic: 7 – 10 days Oliguric: 7 – 10 days Convalescent: 7 – 10 days Normalization of urine sediment Parameter Resolved by Gross hematuria 2 – 3 wks Complement level 6 – 8 wks Proteinuria 3 – 6 mos Micro hematuria 6 – 12mos Lab Dx: U/A – spec grav,cast, hematuria, chonuria Serology – culture of GABS, ASO, C3 ( dec in acute phase, rises during convalescensce) Renal fxn – bun crea- normal, hyponat Hematology – dilutional anemia, transient hypoalbuminemia Radiography – CXR , renal utz Management: Bed rest Fluid and salt restriction Fluids: 400 – 600 ml/m2/day + UO 24H NaCl < 2 g/day K < 40 meq/day Penicillin 50 – 100,000 u/kg/day TID/QID x 10 days HPN, CHF - Furosemide 2 mg/k/dose Prognosis – complete resolution, 5 – 10 % progress to chronic state
Treatment of Hyperbilirubinemia Phototherapy Exchange transfusion IV Ig
Metalloporphyrins
Complications: met. acidosis, electrolyte abn, hypoglycemia, hypocalcemia, thrombocytopenia, vol. overload, arrhythmias, NEC, infection, GVHD, and death Adjunctive treatment for hyperbilirubinemia due to isoimmune hemolytic disease (0.5–1.0 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 inc or G6PD deficiency or when blood products are discouraged (Jehovah’s witness)
PHOTOTHERAPY 10 Bulbs; 20 watts; 200 hrs; 30 cms Bilirubin in the skin absorbs light energy ▪ Photo-isomerization reaction converting the toxic native unconjugated 4Z, 15Z-bilirubin into an unconjugated configurational isomer 4Z,15Ebilirubin, which can then be excreted in bile without conjugation ▪ 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 Complications Loose stools, erythematous macular rash, purpuric rash associated with transient porphyrinemia, overheating, dehydration (increased insensible water loss, diarrhea), hypothermia from exposure, and a benign condition called bronze baby syndrome dark, grayish-brown skin discoloration in infants Bilirubin (Total) Cord Preterm Term 0 – 1 days Preterm Term 1 – 2 days Preterm Term 3 – 5 days Preterm Term Older Infants Preterm Term Adult Neonate Infants/Children
BICARB DEFICIT CORRECTION Ex: wt 4.9kg pH = 7.10 pCO2 = 9.1 pO2 = 36.5 HCO3 = 2.8 BE = -26.8 O2 Sat = 53.6% BE x Wt x 0.3 = 26.8 x 4.9 x 0.3 = 39.39meqs Half correction: 39.39/2 = 19.69 meqs To order: Give 20 meqs NaHCO3 + equal amt of sterile water to be given slow IVTT over 30mins. Infuse another 20 meqs NaHCO3 + equal amt sterile water as drip for 1-2 hrs. EMPIRIC: NaHCO3 1-2mkdose even w/o ABG. HCO3 correction in ABG: Half correction: Base x’s x 0.3 x wt ÷ 2 (+ equal amount of sterile water) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) BUN/ crea ratio Normal 10 -20 > 20 suggest DHN, pre renal azotemia or GIB < 5 – liver disease, inborn error of metabolism
<2 mg/dl <2 mg/dl
<34 µmol/L <34 µmol/L
<8 mg/dl <8.7 mg/dl
<137 µmol/L <149 µmol/L
<12 mg/dl <11.5 mg/dl
<205 µmol/L <197µmol/L
<16 mg/dl <12 mg/dl
<274 µmol/L <205µmol/L
GFR = k x L = ml/min/1.73 m 2 SA sCr L = body length (cm) Scr = mg/dL ; divide by 88.4 if units in mmol/L
<34 µmol/L <21 µmol/L 5 – 12 µmol/L
Dextrosity to get factor:
<2 mg/dl <1.2 mg/dl 0.3 – 1.2 mg/dl Bilirubin (Conjugated) <0.6 mg/dl <0.2 mg/dl
<10 µmol/L <3.4 µmol/L
GFR (based on plasma creatinine and ht)
NURSERY NOTES Desired – D5 D50- D5
D 7.5 = 0.055 D10 = 0.11D 12.5 = 0.166 D15 = 0.22 D 17.5 = 0.28 Limits of Dextrosity: Peripheral line = D12 | Central line = D20
Total Fluid Intake (TFI): Preterm: start at 60 cckd Term: start at 80 cckd To check TFI = rate x 24 ÷ wt ex. Preterm: wt: 1.129 Day 1: start IVF with D10 water 60 x 1.219 ÷ 24 = 3.1 cc/hr x 24 hrs Add Calcium gluconate at 200 mkd q8h Ca gluc = 1.129 x 200 ÷ 3 = 75mg q8hrs for 3 doses Start antibiotics Give ranitidine HGT q 8/12 hrs OGT, CBC Na, K, Ca at 48 hrs Blood c/s depends on AP Day 2: increase TFI by 10-20 (depends on AP) 70 x 1.129 ÷ 24 = 3.3 cc/hr x 24 hrs incorporate ca gluc 200 mkd to IV ex. D10 water 80 cc Ca gluc 2.2cc 82.2cc to run at 3.3ccx24hrs Day 3: increase TFI by 10-20 (depends on AP) If electrolytes are N, may use D10IMB 80 x 1.129 ÷ 24 = rate 80 x 1.129 x factor to get value of D50 water (to make D10 use 0.11) Cont Ca gluc incorporation (if feeding may discontinue) D50 water 9.9cc D5 IMB 77.9cc = D10 IMB Ca gluc 2.2cc (200mkd) 90 cc to run at 3.7cc/hrx24h If feeding already: Total volume of milk ÷ wt = cc/kg/day Subtract this amount to TFI to get value for IV (if Dr. Reinoso, divide by 2 before subtracting to TFI) ex. MF 3cc q3hrs = 24 cc in 24 hrs 24 ÷ 1.129 = 21.2 cckd from milk 80 – 21.2 = 58.8cckd (use this for IVF) 58.8 x 1.129 ÷ 24 = rate D50 water 7.3cc D5 IMB 56.5cc = D10 IMB Ca gluc 2.2cc (200mkd) 66 cc to run at 2.7cc/hrx24h Subsequent days depend on infants status.
Electrolyte requirements: Na: 2-4 mkd prep’n 2.5 mg/ml Ca: 100-200mkd prep’n 100mg/ml K: 2-4 mkd prep’n 2mg/ml Glucose Infusion Rate: Dextrosity x IVF rate x 10 ÷ 10 Wt Ex. 10 kg; IVF D10 IMB at 40cc/h GIR = 10 x 10 x 40 ÷ 10 = 6.6mkmin 60 NV: Newborn & Infants 6-8 mg/kg/min Children 4-6 mg/kg/min If HGT <40 mg/dl, give D10 water slow IV push at 2cc/kg and repeat HGT after 30 mins-1 hr (may do 3 boluses if still low, may inc dextrosity or rate) Level of Umbilical Cathetherization: (cm) If arterial between T6-T9 = Wt x 3 x 8 If venous: (wt x 3) + 8 +1 2 ET tube size: age in yrs +4 4 ET level: if >2yo: age(yrs) +12 or ET size x 3 2 Total Flow Rate = Tidal volume x wt x RR x I.E ratio + 2000 I.E = 2 Dead space = 2000 RR = 40-60 Tidal volume = Newborn: 6-10cck Child: 10-15cck Adult: 15cck FiO2 Nasopharyngeal cathether = Flow rate x 20 + 20 Ex. 1L Fio2 = 40 Nasal catheter = Flow rate x 4 + 20 Ex. 1L FiO2 = 24 Extubation: Give Dexamethasone at 0.1 mkdose q6h for 24 hours prior to extubation USN with epinephrine 0.5 cc + 1.5 cc PNSS q15 mins x 3 doses then extubate then USN with Salbutamol ½ nebule + 1.5 cc PNSS q6h x 24 hours O2 at 10 lpm then decrease as necessary
Double Volume Exchange Therapy (DVET)
Regular milk: 20 cal/oz Preterm milk: 24 cal/oz
Wt x 80 x 2 = Volume/ amt of fresh whole blood (Use mother’s blood type)
Total Caloric Intake: rate x 24 x caloric content of IVF ÷ wt To get factor: Dextrosity x 0.04 = cal/cc
Volume _ = # of exchange aliquots per exchange
Caloric content of IVF D5 = 0.2 cal/cc D7.5 = 0.3 cal/cc D10 = 0.4 cal/cc D15 = 0.6 cal/cc Caloric requirement & Protein requirement Cal/kg 0-5mo 6-11mo 1-2 yo 3-6 yo 7-9 yo 10 – 12 yo 13-15 yo 16 – 19 yo
g/kg
115 110 110 90 – 100 80 – 90 70 – 80 55 – 65 45 – 50 Approximate Daily Water Requirement
0 – 3 do 10 do 1 – 5 mo 6 – 12 mo 1 – 3 yo
120cc/k/d 150cc/k/d 150cc/k/d 140cc/k/d 120cc/k/d
> 3 kg 2-3 kg 1-2 kg 850g-1kg < 850 g
4 – 6 yo 7 – 9 yo 10 – 12 yo 13 – 15 yo 16 – 19 yo
3.5 3 2.5 2 1.5 1.5 1.5 1.5
CHON reqt = CHON reqt for age x IBW Actual BW Growth and Caloric requirements RDA kcal/kg/day 115 110 100 100 100 90 – 100
▪ Diflucan: 6 mkd OD prep’n 50mg/tab divide into pptabs and give 1 ▪
Prepare the ff: 2 pcs 3 way stopcock 1 pc 5 cc syringe 1 pc BT set 1 pc IV tubing 1 pc empty bottle Gloves Calcium gluconate 100 mg every 10 exchanges Criteria for Hypoxic Ischemic Encephalopathy
100 cc/k/d 90 cc/k/d 80 cc/k/d 70 cc/k/d 50 cc/k/d
Estimated Catch up Growth Requirement = cal/k/day (age for wt) x IBW (wt for ht) Actual BW
AGE 0 – 3 mos 3 – 6 mos 6 – 9 mos 9 – 12 mos 1 – 3 yo 4 – 6 yo
pptab OD x 2 weeks Aminophylline: 5mkd (loading dose) then 1.6 mkd q 8 hrs (maintenance) Phenobarbital 20 mkd (loading dose) then 5 mkd (maintenance) Dexamethasone 0.1 mkdose q6hrs x 24 hours
▪ ▪ ▪ For other meds, please see NEOFAX
▪ ▪ ▪ ▪ ▪
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) If using Dobuject: Wt x dose x 60÷ concentration Concentrations: 5mg/ml = 5000 50mg/50ml = 1000 50mg/20ml = 2500 To make 5mg/ml: Dobuject 5cc D5 water 45cc
FWB PRBC Plasma PRP Plt conc Cryoprecipitate
EMERGENCY ET tube age in years + 4 4 ET diameter x 3 >10 yo cuffed
Factor 8 Laryngoscope sizes
PT
Miller 00 or 0
Term
Miller 0
0-6mos
Miller 1
6-24 mos
Miller 2
>24 mos
Miller 2 or Mac 2
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 yo Age in years x 2+ 8 7 – 12 Age in years x 7 – 5 / 2 yo HEAD CIRCUMFERENCE [35 cm (+ 2cm)] 1 – 4 months ½ inch per month 5 – 12 mos ¼ inch per month 2 years old 1 inch per year 3 – 5 yo ½ inch per year 6 – 20 yo ½ inch per 5 years LENGTH (50 cm) 0 – 3 months 9 cm 4–6 8 cm 7–9 5 cm 10 – 12 3cm
20 ml 15 ml 10 ml 5 ml 1-3 ml
1 - 3 days
BLOOD TRANSFUSION 10 - 20 cc/kg 5 - 10 10 - 15 10 - 15 1 u/ 7 -10 kg 1 u/kg Hemophilia A 1 bag (200mg fibrinogen) VW dse 50 -100 mg/kg Fibrinogen dse 100 cc (2-5 kg) Hemophilia A 50 u/kg Hemophilia B 100 u/kg 1 mo
3 – 4H 3 – 4H 1–2H 1–2H FD FD
2mos
6 – 12y
>12y
Hgb
14.5 – 22.5
9 -14
11.5 -15.5
13-16
Hct
.48 - .69
.28 - .42
.35 - .45
.37 - .49
6 -17.5
4.5 -13.5
Wbc
9 -30 birth
Plt
84 – 478 NB
Retic
0.4 - 0.6
5 – 19.5
After 1 wk, same as adult 150 - 400 < 1 -1.2
0.1 -2.9
1 u FWB
(inch = 2.54cm)
= 200 cc PRBC = 50 cc platelet concentrate = 150 – 200cc PRP = 150 cc FFP MCV Hgb / rbc x 10 80 -94 MCH Hgb / rbc x 10 27 - 32 MCHC Hgb/ hct x 10 32 – 38 Absolute reticulocyte count = pt’s hct x retic % N hct for age Reticulocyte Index Absolute Retic Ct > 2 hemorrhage 2 < 2 rbc production abn PRBC to be transfused for correction = 40 – hct x wt
GLUCOSE
PT 20 -60 NB 30 – 60 1 d 40 -60 > 1d 50 -90
Child = 60 -100 Adult = 70-105
ANC - % of neutrophils & cells that become neutrophils – multiplied by wbc ANC = wbc x (% seg + % stabs + % meta) Other formula: wbc x (seg + meta + stabs ) x 10 Ex 2.1 x 53 (seg) x 10 = 1113 ANC > 1000 Normal ANC < 2000 Neutropenia ANC 1000 -1500 Low risk of infection ANC 500 -1000 Mod risk of infection ANC < 500 High risk of infection IT ratio > 0.25 sepsis > 0.80 higher risk of death from sepsis Anemia < 10 g mild anemia 8-9g mod anemia <8 g severe anemia IVIG infusion Preparation: 2.5g/50cc 500g/10cc 25g/100cc 5g/100cc 10g/250cc Computation: Wt x 2 g /kg IVIG Ex wt: 7.2 kg 7.2 x 2 + 16 g IVIG 16 gIVIG 2. 5 g = 320 cc Cc 50cc # of vials = total cc 320cc = 6.4 vials 50cc 50cc 320cc x 0.03 = 9. 6 cc/h for 30 mins Transfuse 9 – 10cc/h IVIG for the 1st 30mins if no reaction, run the remaining volume for 12H Refer for any infusion reactions Close ML Monitor v/s q 30 mins while on infusion If after IVIG if still febrile, rpt IVIG after 3 D If after 2nd IVIG still febrile – start Prednisone Aspirin 80 mkD QID (30 mg, 80, 100, 300 mg)
K (mean value)
KI
LBW < 1 yr
Age
0.33
29.17
FT < 1 yr
0.45
39.78
2-12 y
0.55
48.62
13-21 y (female)
0.55
48.62
13 -21 y (male)
0.70 Age
Range
11 20 50
11 – 15 15 – 28 40 – 65
39 47 58 77
17 – 60 26 – 68 30 – 86 39 -114
6 - 12 mo
103
49 – 157
2 - 19mo
127
62 – 191
2 - 12y
127
89 – 165
Adult males
131
88 – 174
Adult females
117
87 – 147
Preterm 2- 8 d 4 - 28 d 30 -90 d Term 2- 8 d 4 - 28 d 30 - 90 d 1- 6mo
Age (months) 0
Ht (cm) boys 50.5
Ht (cm) girls 49.9
Wt for Ht (cm) 49
Boys (kg) 3.1
Girls (kg) 3.3
1
54.6
53.5
50
3.3
3.4
2
58.1
56.8
51
3.5
3.5
3
61.1
59.5
52
3.7
3.7
4
63.7
62.0
53
3.9
3.9
5
65.9
64.1
54
4.1
4.1
6
67.8
65.9
55
4.3
4.3
7
69.5
67.6
56
4.6
4.5
8
71.0
69.1
57
4.8
4.8
BSA 0 – 5 kg 6 – 10 kg 11 – 20 kg 20 – 40 kg >40 kg
wt x 0.05 + 0.05 wt x 0.04 + 0.10 wt x 0.03 + 0.20 wt x 0.02 + 0.40 wt x 0.01 + 0.80
Age (months) 9
Ht (cm) boys 72.3
Ht (cm) girls 70.4
Wt for Ht (cm) 58
Boys (kg) 5.1
Girls (kg) 5.0
10
73.6
71.8
59
5.4
11
74.9
73.1
60
5.7
12
76.1
74.3
61
5.9
13
77.2
75.5
62
6.2
14
78.3
76.7
63
15
79.4
77.8
16
80.4
17 18
61.88
GFR
Age (months) 35
Ht (cm) boys 95.8
Ht (cm) girls 94.9
Wt for Ht (cm) 84
Boys (kg) 11.7
Girls (kg) 11.4
5.3
36
96.5
95.6
85
11.9
11.6
5.5
3.5 yo
98.4
97.3
86
12.3
11.8
5.8
4
102.9
101.6
87
12.3
11.9
6.1
4.5
106
104.5
88
12.5
12.2
6.5
6.4
5
109.9
108.4
89
12.8
12.4
64
6.8
6.7
5.5
112.6
111.0
90
13.0
12.6
78.9
65
7.1
7.0
6
116.1
114.6
91
13.2
12.8
81.4
79.9
66
7.4
7.3
6.5
118.5
117.1
92
13.4
13.0
82.4
80.9
67
7.7
7.5
7
121.7
120.6
93
13.7
13.3
19
83.3
81.9
68
8.0
7.8
7.5
123.9
123.0
94
13.9
13.5
20
84.2
82.9
69
8.3
8.1
8
127.0
126.4
95
14.1
13.8
21
85.1
83.8
70
8.5
8.4
8.5
129.1
128.8
96
14.4
14.0
22
86.0
84.7
71
8.8
8.6
9
132.2
132.2
97
14.7
14.3
23
86.8
85.6
72
9.1
8.9
9.5
134.4
134.7
98
14.9
14.6
24
87.6
86.5
73
9.3
9.1
10
137.5
138.3
99
15.2
14.9
25
88.5
87.3
74
9.6
9.4
10.5
139.9
140.9
100
15.5
15.2
26
89.2
88.2
75
9.8
9.6
11
143.3
144.8
101
101.0
15.5
27
90.0
89.0
76
10.0
9.8
11.5
145.8
147.6
102
16.1
15.9
28
90.8
89.8
77
10.3
10.0
12
149.7
151.5
103-105
16.5-17.1
16.2-16.7
29
91.6
90.6
78
10.5
10.2
12.5
152.5
154.1
106-108
17.4-18.0
17.0-17.6
30
92.3
91.3
79
10.7
10.4
13
156.5
157.1
109-111
18.3-19.0
17.9-18.6
31
93.0
92.1
80
10.9
10.6
13.5
159.3
158.8
112-114
19.3-20.0
18.9-19.5
32
93.7
92.8
81
11.1
10.8
14
163.1
160.4
115-117
20.3-21.1
19.9-20.6
33
94.5
93.5
82
11.3
11.0
14.5
165.7
161.1
118-120
21.4-22.2
21.0-21.8
34
95.2
94.2
83
11.5
11.2
15
169.0
161.8
121-123
22.6-23.4
22.2-23.1
Age (months) 15.5
Ht (cm) boys 171.1
Ht (cm) girls 162.1
Wt for Ht (cm) 124-126
Boys (kg) 23.9-24.8
Girls (kg) 23.6-24.6
16
173.5
162.4
127-129
25.2-26.2
25.1-26.2
16.5
174.9
162.7
130-132
26.8-27.8
26.8-28.0
17
176.2
163.1
133-135
28.4-29.6
28.7-30.1
17.5
176.7
163.3
136-140
30.2-33.0
30.8-32
18
176.8
163.7
141-145
33.7-36.9
Weight for Height = Actual BW (kg) P50 Wt for Ht (kg) Waterloo Classification Normal Mild Moderate Severe Epinephrine Amiodarone Cardioversion Albumin
Height for Age = Actual Height (cm) P50 Ht for Age
Wasting (Wt for Ht) >90 81 – 90 70 – 80 <70
Stunting (Ht for Age) >95 90 – 95 85 – 89 <85
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
Epinephrine Drip
0.1 – 1mg/k/min; 1amp = 1mg/ml Rate = (wt x dose x 60)/desired Ex: (18kg x 0.1 x 60)/100 = 2cc/hr To order: 5 amps Epi + 50cc D5W to rum at 2cc/hr (0.1mg/k/min)
Levophed
0.3-2mcg/k/min Prep: 4mg/amp (1mg/ml) Rate = (wt x dose x 60)/desired Ex. Dose 0.5 1mg/20 = 0.05 x 1000 = 50mcg/ml (18kg x 0.5 x 60)/50 = 10.8cc/hr To order: 1 amp levophed + 80 cc D5W to run at 11cc/hr
CEPHALOSPORINS 1st Generation Cefalexin (25 – 100 mkd ) q 6-8 h Lexum Cap : 250mg; 500mg Cefalin Susp : 125mg/5ml 250mg/5ml Keflex Drops : 100mg/ml Ceporex Cap : 250mg 500mg Selzef Caplet: 1 gm Granules: 125mg/5ml 250mg/5ml Drops: 125mg/1.25ml 2nd Generation Cefaclor (20 – 40 mkd ) q 8 – 12 h Ceclor Pulvule: 250mg 500mg 375mg Ceclor CD 750mg CD ext release Susp: 125mg/5ml 187mg/5ml 250mg/5ml 375mg/5ml Drops: 50mg/ml Xelent Cap : 250mg 500mg Vercef Susp : 125mg/5ml 250mg/5ml Cefuroxime (20 – 40mkd) q 12h Zinnat Cap : 250mg 500mg Sachet: 125mg/sat 250mg/sat Susp: 125mg/5ml Cefprozil (20 – 40mkd) q 12h Procef Susp : 125mg/5ml 250mg/5ml 3rd Generation Cefixime (6 – 12 mkd) q 12h Tergecef Susp : 100mg/5ml Zefral Drops: 20mg/ml Ultrazime Cefdinir (7mg/kg q 12h OR 14mg/kg OD) Omnicef Cap : 100mg Sachet/ Susp: mg/5ml COTRIMOXAZOLE (TM 5 – 8 mkd) q 12h Bactille – TS Susp/5ml SMZ 400mg TM 80mg Tab 800mg 160mg Bacidal Susp/5ml 400mg 80mg Trizole Susp/5ml 400mg 80mg Globaxole
Tab Susp/5ml
800mg 400mg
160mg 80mg
Dopamine
Renal dose Pressor alpha effect
3-5 >5 - <15 >15
ANAPHYLAXIS 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 Epinephrine (1:1000)
ANTIBIOTICS Amoxicillin (30 – 50 mkday) TID Pediamox Susp : 250mg/5ml Drops : 100mg/ml Himox Cap : 250mg, 500mg Moxicillin Susp : 125mg/5ml 250mg/5ml Harvimox Drops : 100mg/ml Novamox Amoxil Susp : 125mg/5ml 250mg/5ml Cap : 250mg 500mg Glamox Drops : 100mg/ml Globapen Amoxicillin + Clavulanic acid (30 – 50 mkday) Augmentin Tab: 375mg (250mg); 625 (500mg) Amoclav Susp: 156.25mg/5ml (125mg) TID 228.5mg/5ml (200mg) BID 312.5mg/5ml (250mg) TID 457mg/5ml (400mg) BID Cloxacillin (50 – 100 mkday) q6h Prostaphlin A Tab: 250mg 500mg Orbinin Susp: 125mg/5ml Flucloxacillin (50 – 100 mkday) q6h Staphloxin Susp: 125mg/5ml Cap : 250mg 500mg Chloramphenicol (50 – 75 mkd) q6h Pediachlor Susp: 125mg/5ml Chloramol Tab : 250mg 500mg Kemicetine Chloromycetin
Trimethoprim + Sulfadiazone (TM 5 – 8 mkd) Triglobe Tab Sdz 410mg TM 90mg Forte 820mg 180mg Susp/5ml 205mg 45mg AMINOGLYCOSIDES Tetracycline 25 – 50 mkday q6h Doxycycline 5 mkday BID Furaxolidone 5 – 8 mkday q6h MACROLIDES Erythromycin (30 – 50 mkd) q 6h Macrocin Susp: 200mg/5ml Ethiocin Drops: 100mg/2.5ml Erycin Cap : 250mg 500mg Susp: 200mg/5ml Drops: 100mg/2.5ml Erythrocin Film tab: 250mg 500mg Granules: 200mg/5ml DS Granules: 400mg/5ml Drops: 100mg/2.5ml Ilosone/ Tab: 500mg DS Liquid: 200mg/5ml Ilosone DS Pulvule: 250mg Drops: 100mg/ml Liquid: 125mg/5ml Clarithromycin (6 – 15 mkday OR 7.5 mkdose q12h) Klaricid Susp : 125mg/5ml 50mg/5ml Klaz Tab: 250mg 500mg Roxithromycin <6 yo 5 – 8 mkd BID 6 – 12 yo 100mg/tab BID Macrol/Rulid Rulid dispensable Azithromycin
Zithromax Clindamycin
Tab: 150mg Ped Tab: 100mg Tab: 50mg 3 day regimen: 10 mkday x 3 days 5 day regimen: 10 mkd on day 1 5 mkd on day 2 to 5 Adult: 500mg OD day 1/250mg OD day 2 to 5 Susp: 250mg/5ml Sachet: 200mg/sachet Cap : 250mg PO: 20 – 30 mkday q 6 – 8h IV: 25 – 40vmkday q 6h Susp: 75mg/5ml Cap: 150mg 300mg Amp: 150mg/ml
Oxantel + Pyrantel pamoate Trichiuriasis: x 2 days Quantrel
IV ANTIBIOTICS Penicillin
50,000 – 100,000 ukd q 6h
Amoxicillin
50 – 100 mkd q 6 – 8 h
Ampicillin
50 – 100 mkd q 6 – 8 h
Chloramphenicol
50 – 100 mkd q 4 – 6 h
Ampi + Cloxa
50 – 100 mkd q 6 h
Oxacillin
50 – 100 mkd q 6 – 8 h
Flucloxacillin
50 – 100 mkd q 6 – 8 h
Gentamicin
5 – 7.5 mkd OD
Netromycin
5mkd q 12 h
Amikacin
15mkd q 12 h
Cephalexin
50 – 100 mkd q 6 h
Cefuroxime
50 – 100 mkd q 6 – 8 h
Ceftriazone
50 – 100 mkd OD
Ceftazidime HYDROCORTISONE
50 – 100 mkd q 12 h
Acyclovir Zovirax Acevir
Mebendazole Antiox
Albendazole
Zentel
AMOEBICIDES PO: 30 – 50 mkday q 8h IV: 30 mkday q 8h Anaerobia Susp : 125mg/5ml Tab : 250mg Servizol Susp: 200mg/5ml Tab : 250mg 500mg Flagyl Susp : 125mg/5ml Tab : 250mg 500mg Etofamide (15 – 20 mkd) TID Kitnos Susp : 125mg/5ml Tab : 200mg 500mg Diloxanide furoate (20mkd) q8h x 10 days Furamide Tab : 500mg Dilfur Susp: 125mg/5ml Secnidazole Flagentyl 2 tab now then 2 tabs after 4 hrs Ercefuryl (20mkday) Metronidazole
LD: 10 mkdose MD: 5 mkdose q 6, 8 or 12h *max dose: LD 200 MD 100
ANTIVIRAL (20 mkdose) q 4 – 6 h Max 800mg/day x 5 days Susp: 200mg/5ml Blue: 400mg Pink: 800mg ORAL ANTIFUNGALS
Ketoconazole (6mkd) q 4 – 6h Daktarin
Adult & Child: ½ tsp q 6h Infant: ¼ tsp q 6 h
Nystatin Mucostatin Susp: 100,000 u/5ml Ready mix susp Tab: 500,000 u Fluoconazole (3 – 6 mkd) OD x 2wks Diflucan
Isoniazid Comprilex Nicetal Trisofort Odinah
Rifampicin Natricin Rifadin Rimactane Rimaped Pyrazinamide (PZA) CIBA Zcure Zinaplex
Solmux
Solmux Broncho Solmux Chewable tab
Cap: 50mg 150mg Vial: 2mg/ml x 100 ml
ANTI-HELMINTHICS (10 – 20 mkd) SD Hookworm: x 3 days Susp : 125mg/5ml Tab : 125mg 250mg *not recommended below 2 yo Susp: 50 mg/ml 100mg/ml Tab: 125mg 250mg 100 mg BID x 3 days 500mg SD (>2 yo) <2 yo: 200mg SD >2yo: 400mg SD *may give x 3 days if with severe infestation Susp: 200mg/5ml Tab : 400mg
Diazepam
Midazolam
200mg
Phenobarbital
ANTI-TB MEDS (10 – 12 mkd) ODAC or 2hrs PC Suspension: 200mg/5ml 100mg/5ml 200mg/5ml 150mg/5ml Tablet 400mg (10 – 20 mkd) ODAC or 2hrs PC 100mg/5ml 200mg/5ml 100mg/5ml 100mg/5ml 200mg/5ml Tablet 300mg 450mg (16 – 30 mkd) BID/TID 250mg/5ml
Carbocisteine
500mg/5ml Tablet 500mg
Ambroxol
MUCOLYTIC Drops: 40mg/ml 1 – 3 mos: 0.5ml QID 3 – 6 mos 0.75ml 6 – 12 mos 1ml 1 – 2 yo 1.5 ml Susp: 100mg/5ml 200mg/5ml 2 – 3 yo 5ml 2.5ml 4 – 7 yo 10ml 5 ml 8 – 12 yo 15ml 7.5ml Forte: 500mg/5ml Cap: 500mg Adult & >12 yo: 5 – 10ml 1 cap Capsule Suspension Tab: 500mg 1 tab q 8h
Lovsicol
TID/
Mucosolvan
Ambrolex Zobrixol
ANTICONVULSANT 0.2 – 0.3 mkdose Drip: 1amp in 50cc D5 W 10mg/amp 0.15 mkdose OR 0.05 – 0.2 mkdose LD: 10 mkdose q 12h MD: 5 mkdose q 12h Infant Drops <3mos 3 – 5 mos 6 – 8 mos 9 – 12 mos Ped Syr 1 – 3 yo 4 – 7 yo 8 – 12 yo Adult Susp Adult & >12 yo Capsule Adult & >12 yo
QID 0.25ml 0.5ml 0.75ml 1ml TID 5 – 7.5ml 7.5 – 10ml 10 – 15ml TID 10 – 15ml TID 1 cap
1 – 1 ½ tsp 1 ½ - 2 tsp 2 – 3 tsp 2 – 3 tsp
Infant drops 50mg/ml Ped Syrup 100mg/5ml Adult Susp 250mg/5ml Cap 500mg Infant drops 6mg/ml 75mg/ml BID < 6 mo 0.5ml 0.5ml 7 – 12 mo 1 ml 0.75ml 13 – 24 mo 1.25ml 1ml Pedia Syrup <2 yo 2.5ml BID 2 – 5 yo 2.5ml TID 5 – 10 yo 5ml TID Adult Syrup: Adult & >10 yo = 5ml TID Retard cap: Adult & >10 yo = 1 cap OD Tab: Adult & >10 yo = 1 tab TID Inhalation <5 yo 1 – 2 inhalation of 2ml soln daily Adult & children >5 yo = 1 – 2 inhalation of 2 – 3ml soln daily Infant drops 6mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Retard cap 75mg Tab 30mg Inhalation Soln 15mg/2ml Ampule 15mg/2ml Infant drops 7.5mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Tab 30mg
Salbutamol Ventolin
Ventar Hivent Syrup Salbutamol + Guaifenesin Asmalin Broncho Pulmovent Terbutaline sulfate Terbulin Pulmoxel Bricanyl Doxophelline Ansimar Procaterol HCl Meptin
Theophylline Ranitidine Zantac Cimetidine
Tagamet
Famotidine
Butamirate citrate
B2 AGONIST (0.1 – 0.15 mkdose) Tab 2mg Syr 2mg/5ml Nebule 2.5mg/2.5ml Tab 2mg Syr 2mg/5ml
DECONGESTANT Nasal NaCl Salinase Muconase Oxymetazoline HCl
Tab 1 tab TID Syrup 2 – 6 yo 5 – 10 ml BID/TID 7 – 12 yo 10ml ( 0.075 mkdose) Tab 2.5mg Tab 2.5mg Nebule 2.5mg/ml Syr 1.5mg/5ml Tab 2.5mg Nebule 5mg/2ml Syr 1.5mg/5ml Expectorant (6 – 8 mkdose) BID x 7 – 10 days Syrup 100mg/5ml Tab 400mg (0.25ml/kg) Syrup 5mcg/ml Tab 25mcg Nebuliser soln 100mcg/ml 10 – 20 mkdose 3 – 5 mkdose H2-BLOCKER 1 – 2 mkdose q 12h Tab 75mg 150mg 300mg Neonates: 5 – 20 mkday q6 – 12 h Infants: 10 – 20 mkday Child; 20 – 40 mkday Adult: 300mkdose QID 400mkdose BID 800mkdose QID Susp: 300mg/5ml Tab: 100mg 200mg 300mg 400mg 800mg PO: 0.5 mkdose q 12 h IV: 0.6 – 0.8 mkday q 8 – 12h ANTITUSSIVES 3 yo >6 yo >12 yo Adult
Sinecod Forte Dextromethorphan + Guaifenesin Robitussin – DM
5 ml TID 10ml TID 15ml TID 15ml QID 1 tab TID/QID Syrup 7.5mg/5ml Tab 50mg 2 – 6 yo 6 – 12 yo Adult Syrup
2.5 – 5ml 5ml 5 – 10ml
q 6 – 8h q 6 – 8h q 6h
ANTIHISTAMINE Diphenhydramine HCl (5mkd) q 6h | IM/IV/PO: 1 – 2 mkdose Benadryl Syr: 12.5mg/5ml Inj: 50mg/ml Cap: 25mg 50mg Hydroxyzine (1mkd) BID Adult: 10mg BID 25mg ODHS Iterax Syr: 2mg/ml Tab: 10mg 25mg 50mg Ceterizine (0.25mkdose) 6mos - <12mos : 1ml OD 12mos - <2 yo: 1ml OD/BID 2 – 5 yo: 2ml OD / 1ml BID 6 – 12 yo: 10ml (2 tsp)OD/ 5ml BID 1 tab OD/ ½ tab BID Adult & >12yo: 1 tab OD Virlix Oral drops: 10mg/ml Tab: 10mg Oral soln: 1mg/ml Allerkid Drops: 2.5mg/ml Syr: 5mg/5ml Alnix Drops: 2.5mg/ml Tab: 10mg Syr: 5mg/5ml Loratadine 1 – 2 yo: 2.5 ml BID 2 – 12 yo (<30 kg): 5ml OD (>30 kg): 10ml OD Adult & > 12 y : 1 tab OD Claritin/Allerta/Loradex Syr: 5mg/ml Tab: 10mg Desloratadine 6 – 12 mos: 2ml OD 1 – 5 yo: 2.5ml OD 6 – 12 yo: 5ml OD Aerius Syr: 2mg/5ml Tab: 5mg
Drixine Xylometazoline HCl
2 – 4 drps/spray per nostril TID/QID 2 sprays/nostril then suction q6h x 3 days Nasal spray Nasal drops 2 – 5 yo: 2 – 3 drops/nostril BID >5 yo: 2 – 3 sprays/nostril BID Nasal spray: 0.05% Nasal soln: 0.025% < 1 yo: 1 – 2 drps OD/BID 1 – 6 yo: 1 – 2 drps OD/BID max TID Adult: 2 – 3 drps / 1 squirt TID max QID
Otrivin Oral Phenylpropanolamine HCl (0.3 – 0.5 mkdose) Disudrin 1 – 3 mos: 0.25 ml 4 – 6 mos: 0.5 ml 7 – 12 mos: 0.75 ml 1 – 2 yo: 1 ml 2 – 6 yo: 2.5 ml 7 – 12 yo: 5 ml Drops: 6.25ml q6h Syr: 12.5mg/5ml q6h Brompheniramine maleate + PPA Dimetapp 1 – 6 mos: 0.5ml TID/QID 7 – 24 mos: 1ml TID/QID 2 – 4 yo: ¾ tsp 4 – 12 yo: 5ml Adult: 5 – 10 ml 1 tab BID Infant drops: (0.1mkdose) Syr Extentab Carbinoxamine maleate + Phenylephrine HCl Rhinoport 1 – 5 yo: 5ml 6 – 12 yo: 10ml Adult & > 12yo: 1 cap / 15ml Syrup Cap Loratadine + PPA Loraped <30 kg: 2.5ml BID >30 kg: 5ml BID Syrup: 5mg/ml ANTIPYRETIC (10 – 20 mkdose) q 4h Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 325mg 500mg Calpol Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Defebrol Syrup: 120mg/5m 250mg/5ml Afebrin Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 600mg Tylenol Drops: 80mg/ml Syrup: 160mg/5ml Naprex Drops: 60mg/0.6ml Syrup: 250mg/5ml Inj: 300mg/2ml Rexidol Drops: 60mg/0.6ml Syrup: 250mg/5ml Tablet: 600mg Biogesic Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Tablet: 500mg Aeknil Ampule (2ml) 150mg/ml Opigesic Suppository: 125mg 250mg Mefenamic Acid (6 – 8mkdose) q 6h Ponstan Suspension: 50mg/5ml Cap SF: 250mg Tab: 500mg Aspirin (60 – 100 mkd) Ibuprofen (5 – 10 mkday) q8h (max 20mkday) Paracetamol Tempra
Dolan FP Dolan Forte Advil
Suspension: 100mg/5ml 200mg/5ml Drops: 100mg/2.5ml 100mg/5 Tab: 200mg
BID BID BID
Dicycloverine Relestal Domperidone
Motilium Vometa
ANTISPASMODIC 6mos – 2 yo 0.5 – 1ml Drops 5mg/ml Syrup 10mg/5ml 0.3 – 0.6 mkdose q 6 – 8 h 2.5 – 5ml/10kg BW TID Dyspepsia: 2.5/10kg TID Nausea: 2.5 – 5ml/kg TID 0.3 – 0.6 ml/5kg BW TID/QID Susp 1mg/ml Tab Oral drops Susp
5mg/ml 5mg/5ml
Tab
TID
10mg 10mg
INHALED STEROIDS Budesonide Budecort
Flexotide neb ORAL STEROIDS Prednisone Prednisolone Liquidpred Maalox (plain, plus) Simethicone Restime
Hydralazine Apresoline Spirinolactone
250mcg q 12h 500mcg q 12h 500mcg OD for allergic rhinitis 250mcg /ml (2ml) 500mcg /ml (2ml) 250mcg /ml (2ml) 250mcg q 12h LD: 10mkdose 200mg MD: 5mkdose 1 – 2 mkday 1 – 2 mkday Syrup 15mg/5ml ANTACIDS 5ml/10kg Available in 180ml bottle < 2 yo 2 – 12 yo Oral drops
0.5ml 4ml 40mg/ml
qid qid
ANTIHYPERTENSIVES PO: 0.75 – 1.0 mkday q 6 – 12 h IV: 0.1 – 0.2 mkdose 1 – 3 mkday
Edited by: frankydinks (2015)
