BODY TEMPERATURE Subnormal Normal Subfebrile Fever High fever Hyperpyrexia
ABG
<36.6°C 37.4°C 35.7 – 38.0°C 38.0°C >39.5°C >42.0°C
AGE
HR (bpm)
BP (mmHg)
Preterm Term 0-3 mo 3-6 mo 6-12 mo 1-3 yrs 3-6 yrs 6-12 yrs 12-17 yrs
120-170 120-160 100-150 90-120 80-120 70-110 65-110 60-95 55-85
55-75/35-45 65-85/45-55 65-85/45-55 70-90/50-65 80-100/55-65 90-105/55-70 95-110/60-75 100-120/60-75 110-135/65-85
pH: pCO2: pO2:
7.35-7.45 35-45 80-100
ANTHROPOMETRIC MEASUREMENTS
HCO3: B.E.: O2 sat:
22-26mEq/L +/- 2mEq/L 97%
NORMAL LABORATORY VALUES RR (cpm) 40-70 30-60 35-55 30-45 25-40 20-30 20-25 14-22 12-18
RBC
NB 4.8-7.1
Infant 3.8-5.5
WBC PMNs Lymph Hgb
9-30,000 61% 31% 14-24
6-17,500 61% 32% 11-20
Hct
44-64%
35-49
Platelets 140-300 200-423 Ret 2.6-6.5 0.5-3.1
Child 3.8-5.
Adole M: 4.6-6.2 F: 4.2-5.4 5-10,000 6-10,000 60% 60% 30% 30% 11-16 M: 14-18 F: 12-16 31-46 M: 40-54 F: 37-47 150-450 150-450 0-2 0-2
IDEAL BODY WEIGHT Age At Birth
Kilograms 3kg (Fil) 3.35kg (Cau) Age (mo) + 9 / 2
3-12 mo 1-6 y 7-12 y
Pounds 7 Age (mo) + 10 (F) Age (mo) + 11 (C) Age (y) x 5 + 17 Age (y) x 7 + 5
Age (y) x 2 + 8 Age (y) x 7 – 5 / 2
Given Birth Weight: Age Using Birth Weight in Grams < 6 mo Age (mo) x 600 + birth weight (gm) 6-12 mo Age (mo) x 500 + birth weight (gm) Expected Body Weight (EBW): Term Age in days – 10 x 20 + Birth Weight Pre-Term Age in days – 14 x 15 + Birth Weight
BP cuff should cover 2/3 of arm -: SMALL cuff: falsely high BP -: LARGE cuff: falsely low BP
COUNT (%) BT CT PTT
BMI Asian <18.5 18.5 – 22.9 ≥ 23.0 23 – 24.9 25 – 29.9 ≥ 30
Underweight Normal Overweight at risk Obese I Obese II
Caucasian <18.5 18.5 – 24.9 25 – 29.9
1-5 min 1-6 5-8 min 5-8 12-20sec 12-14
1-6 5-8 12-14
Age of Infant 4-5 months 1 year 2 years 3 years 5 years 7 years 10 years
1-6 5-8 12-14
Ideal Weight 2 x Birth Weight 3 x Birth Weight 4 x Birth Weight 5 x Birth Weight 6 x Birth Weight 7 x Birth Weight 10 x Birth Weight
30 – 39.9 >40 APGAR
LENGTH / HEIGHT (50 cm) Age At Birth 1y 2-12 mo
Centimeters 50 75 Age x 6 + 77
Age Inches 20 30 Age x 2.5 + 30
Transverse-AP Diameter ratio 1.0 1.25 1.35
At Birth 1y 6y
Inches Transverse = AP Transverse > AP Transverse >>> AP
FONTANELS Gain in 1st Year is ~ 25cm + 9 cm 3 cm per mo + 8 cm 2.67 per mo + 5 cm 1.6 cm per mo + 3 cm 1 cm per mo
Age 0-3 mo 3-6 mo 6-9 mo 9-12 mo
Appropriate size at birth: Closes at: Anterior
Age At Birth < 4 mo
Inches 35 cm (13.8 in) + 2 in (1/2 inches / mo) + 2 in (1/4 inches / mo) + 1 inch + 1.5 in (1/2 inches / year) + 1.5 in (1/2 inches / year)
5-12 mo 1-2 yrs 3-5 yrs 6-20 yrs
TI =
+ 5.08cm (1.27cm / mo) + 5.08cm (0.635cm / mo) 2.54 cm + 3.81cm (1.27cm / mo) + 3.81cm (1.27cm / mo)
AGE Birth or 6 wks
DPT
6 wks
DOSE 0.05mL (NB) 0.1mL (older) 0.5mL
OPV HEPA B
6 wks 6 wks
2 drops 0.5mL
3 3
PO IM
MEASLES
9 mos
0.5mL
1
SC
BCG-2
School entry
0.1mL
1
ID
TetToxoid
Childbearing women
0.5mL
3
IM
ROUTE ID
SITE RDeltoid
3
IM
Upper Outer thigh Mouth Anterolateral thigh Outer upper arm LDeltoid Deltoid
Safety ◦ Use seatbelts/helmets? ◦ Enter into high risk situations? ◦ Member of frat/sorority/orgs? ◦ Firearm at home? F.R.I.C.H.M.O.N.D.
◦ ◦ ◦ ◦ ◦ ◦ ◦
Fluids Respiration Infection Cardiac Hematologic Metabolic Output & Input [cc/kg/h] N: 1-2
A
(-) Movement
Some flexion / extension
R
Absent
Slow / Irregular
transverse chest diameter AP diameter Birth 1 year 6 years
Verbal
Infants/Young 4- Spontaneous 3- To speech 2- To pain 1- None 5- Appropriate 4- Inconsolable 3- Irritable 2- Moans 1- None 6- Spontaneous 5- Localize pain 4- Withdraw 3- Flexion 2- Extension 1- None
GCS
: 1.0 : 1.25 : 1.35
Older Spontaneous To speech To pain None Oriented Confused Inappropriate Incomprehensible None Spontaneous Localize pain Withdraw Flexion Extension None
ADVERSE REACTIONS FROM VACCINES INTERVAL
BCG
DPT OPV HEPA B MEASLES
4 wks 4 wks
1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks 2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis 1. Fever, local soreness 2. Convulsions, encephalitis / encephalopathy, permanent brain damage Paralytic Polio Local soreness 1. Fever & mild rash 2. Convulsions, encephalitis / encephalopathy, SSPE, death
4 wks
1 mo then 6-12 mos
H.E.A.D.S.S.S.
Suicide/Depression ◦ Ever sad/tearful/unmotivated/hopeless? ◦ Thought of hurting self/others? ◦ Suicide plans?
Grimaces
Motor
# 1
Sexual activities ◦ Sexual orientation? ◦ GF/BF? Typical date? ◦ Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs?
(-) Response
Function Eye Opening
EXPANDED PROGRAM ON IMMUNIZATION VACCINE BCG-1
G
P
2 Completely pink > 100 Coughs, Sneezes, Cries Active movement Good, strong cry
Normal Mild / Moderate Asphyxia Severe asphyxia
THORACIC INDEX
Centimeters
1 Pink body/ Blue extremities Slow (<100)
A
8 – 10: 4 – 7: 0 – 3:
Posterior
HEAD CIRCUMFERENCE (33-38 cms)
2 x 2 cm (anterior) = 18 months, or as early as 9-12 months = 6 – 8 weeks or 2 – 4 months
0 Blue / Pale Absent
H.E.A.D.S.S.S. Home Environment ◦ With whom does the adolescent live? ◦ Any recent changes in the living situation? ◦ How are things among siblings? ◦ Are parents employed? ◦ Are there things in the family he/she wants to change? Employment and Education ◦ Currently at school? Favorite subjects? ◦ Patient performing academically?
◦ ◦ ◦ ◦
Have been truant / expelled from school? Problems with classmates/teachers? Currently employed? Future education/employment goals?
Activities ◦ ◦ ◦ ◦ Drugs ◦ ◦ ◦
What he/she does in spare time? Patient does for fun? Whom does patient spend spare time? Hobbies, interests, close friends?
Used tobacco/alcohol/steroids? Illicit drugs? Frequency? Amount? Affected daily activities? Still using? Friends using/selling?
ACTIVE BCG DPT OPV Hep B Measles Hib MMR Tetanus Toxoid Varicella
PASSIVE Diphtheria Tetanus Tetanus Ig Measles Ig Rabies (HRIg) Hep A Ig Hep B ig Rubella Ig
NUTRITION
AGE 0-5 mo 8-11 mo 1-2 y 3-6 y 7-9 y 10-12 y 13-15 y 16-19 y
WT. 3-6 7-9 10-12 14-18 22-24 28-32 36-44 48-55
TCR β TCR
CAL 115 110 110 90-100 80-90 70-80 55-65 45-50
CHON 3.5 3.0 2.5 2.0 1.5 1.5 1.5 1.2
= Wt at p50 x calories = CHON X ABW
Total Caloric Intake
: calories X amount of intake (oz)
Gastric Capacity
: age in months + 2
Gastric Emptying Time
: 2-3 hours
1:1 Alacta Enfalac Lactogen Lactum Nan Nestogen Nutraminogen Pelargon Prosobee
1:2 Bonna Nursoy Promil S-26 Similac SMA
THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE by Stephen R. Covey
Habit 1: Habit 2: Habit 3: Habit 4: Habit 5:
Be Proactive Begin with the end in mind Put First Things First Think Win-Win Seek first to understand and then to be understood Habit 6: Synergize Habit 7: Sharpen the saw
EXPECTED LA SALLIAN GRADUATE ATTRIBUTES (ELGA) 1. Competent & safe physicians 2. Ethical & socially responsible Doctors / practitioners 3. Reflective lifelong learners 4. Effective communicators 5. Efficient & innovative managers
TREATMENT PLAN A ACUTE DIARRHEA (at least 3x BM in 24 hrs) 4 Rules of Home Treatment
DIARRHEA
◦ ◦ ◦
Chronic
: >14 days, non-infectious causes
Persistent
: >14 days, infectious cause
ORS vol. after each loose stool 1 day <24 mo 2-10 y.o. >10 y.o.
5-100mL 100-200mL As much as wanted
500mL 1000mL 2000mL
For severe dehydration / WHO hydration (fluid: PLR 100cc/kg) Age <12 >12
30mL/kg 1H 30 mins
75mL/kg 5H 2½H
Patient in SHOCK ◦ ◦ ◦
20-30cc/kg IV fast drip but in infants 10cc/kg IV (repeat if not stable) If responsive & stable 75/kg x 4-6 hours
TREATMENT PLAN C ETIOLOGY of AGE Treat severe dehydration QUICKLY! 4 Major Mechanisms Bacteria Viruses 1. Give extra fluid (as much as the child Aeromonas Start IV fluid immediately Astroviruses take) 1. will Poorly absorbed osmotically active substances in Bacillus cereus Caloviruses lumen Campylobacter If jejuni the child can drink, give Norovirus ORS by Breastfeed frequently(increased) & longer atoreach feeding 2. > Intestinal ion secretion decreased Clostridium perfringens > if the child is exclusively breastfed, give one or mouth while the IV drip is beingEnteric set up Adenovirus absorption Clostridium difficile Rotavirus more of the following in addition to breastmilk Escherichia coli Cytomegalovirus Give 100mL/kg Lactated Ringer’s Outpouring ◦ ORS solution into the lumen of blood, Plesiomonas Herpes simplex virus solution shigelbides mucus Salmonella food based fluid (e.g. soup, rice, water) 4. Derangement of intestinal motility TREATMENT PLAN B Shigella clean water First give Then give Age Staphylococcus aureus 30mL/kg in: 70mL/kg in: Recommended amount of ORS over 4 hour period Vibrio cholerae 01 & 0139 How much fluid to be given in addition to the usual Infants Rotaviral AGE (vomiting first then diarrhea) 5 hours Vibrio parahaemolyticus1 hour* fluid intake? Age up to: 4 mo – 4 mo 12 mo – 12(<12mo) mo 2 yrs – 2 yrs 5 yrs Yersinia enterocolitica Ingestion of rotavirus ► rotavirus in intestinal villi Wt: <6kg 6-9.9kgChildren 10-11.9kg 2-19kg 30 min* 2 ½ hours Up to 2 years:►destruction 50-100 mL after each of villi (12mo-5yrs) 700-900 (mL) 200-400 400-700 900-1400 Parasites loose stool Balantidium coli (secretory diarrhea ▼absorption ▲ secretion) ► AGE ◦ Use known Blastocyctis hominis 2 years or more: 140-200 mL child’s age only when weight is not Repeat once if radial pulse is very weak or not Approximate amount of ORS (mL) Cryptosporidium :- give frequent small sips◦ from a cup detectable Giardia lamblia :- if the child vomits, wait for 10 min then Assessment of dehydration (Skin Pinch Test) CHILDS WT (kg) x 25 resume ◦ (+):-if >continue 2 seconds reassess the child every 15-30 min. giving extra fluids diarrhea ◦ ifuntil the child wants more ORS than shown, give more Amoeba Metronidazole if dehydration is not improving, stops giveback frequent small sips from a cup no dehydration if skin tenting◦ goes Al/mebendazol give IVAscariasis fluid more rapidly ◦ if the child vomits, wait for 10 min then resume immediately e 2. Give Zinc supplements ◦ continue breastfeeding whenever the child wants ◦ also give ORS (~5mL/kg/hr) as soon as the child Cholera Tetracyline can drink [usually after 3-4 hours in infants; 1-2 Shigella TMP/SMX Up to 6 mo: 1 half tab per day for 10-14 days AFTER 4 HOURS hours in children] (Cotri) 6 months or more: 1 tab or 20mg ◦ reassess the child & classify dehydration status Salmonella Chloramphenic OD x 10-14 days reassess after 6 hrs (infant) & 3 hrs (child) ◦ select the appropriate plan to continue◦ treatment ol ◦ begin feeding the child while at the clinic 3. Continue feeding
1. 2.
3.
◦
3.
◦
◦
IV-FLUID COMPOSITIONS (Commonly Used for Infants and Child): ORS
Glucose: 100mmol/L Na: 60 mol/L K: 20 mmol/L
Cl: 50mmol/L Mg: 5mmol/L Citrate: 10 mmol/L
•
Hydrite -: 2 tab in 200ml water or 10sachets in 1L water Glucose: 111mmol/L Na: 90 mmol/L K: 20 mmol/L
Cl: 80mmol/L HCO3: 5mmol/L
Pedialyte 45 0r 90 -: prevention of DHN & to maintain normal fluidelectrolyte balance in mild to moderate dehydration. Glucose 45mEq Na: 20mEq K: 35mEq Citrate: 30mEq Dextrose: 20g
Gluconate: 5mmol/L
•
Child Age 2months up to 5years
•
ETIOLOGY OF PNEUMONIA
Glucolyte 60 -: for acute DHN secondary to GE or other forms of diarrhea except CHOLERA. In burns, postsurgery replacement or maintenance, mild-salt loosing syndrome, heat cramps and heat exhaustion in adults.
Glucose: 11mml/L Na: 90 mmol/L K: 20 mmol/L
Glucose 90mEq Na: 20mEq K: 80mEq Citrate: 30mEq Dextrose: 25g
Pedialyte mild 30 -: to supplement fluid & electrolyte loss due to active play, prolonged exposure, hot and humid environment
Young Infants < 2months old
ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)
•
Glucose: 30mEq Na: 20mEq K: 30mEq
Mg: 4mEq lactate: 20mEq Ca: 4mEq Energy: 20kcal/ 100ml
Bacterial - Streptococcus pneumoniae - Group B streptococci (neonates) - Group A streptococci - Mycoplasma pnemoniae (adolescents) - Chlamydia trachomatis (infants) - Mixed anearobes (aspiration pneumonia) - Gram negative enteric (nosocomial pneumonia) Viral - Respiratory syncitial virus - Parainfluenza type 1-3 - Influenza types A, B - Adenovirus - Metapneumovirus Fungal - Histoplasma capsulatum - Cryptococcus neoformans contact) - Aspergillus sp. (immunosuppressed) - Coccidioides immitis - Blastomyces dermatitides - Pneumocystis carinii
(Croup)
(bird, bat contact) (bird (immunosuppressed) Mucormycosis
(immunosuppressed, HIV, steroids)
SMR GIRLS LUDAN’S METHOD (HYDRATION THERAPY) MODERATE DEHYRATION 100 cc/kg 60 cc/kg st 1 hr: ¼ Plain LR Next 5-7 hrs: ¾ D5 0.3% in 5-7 hours
SEVERE DEHYDRATION 150 cc/kg 90 cc/kg st 1 hr: ⅓ Plain LR Next 5-7 hrs: ⅔ D5 0.3% in 5-7 hours
NOTE:
TOTAL FLUID REQUIREMENT 100 mL / kg 1000 + [ 50 for each kg in excess of 10 kg] 1500 + [ 20 for each kg in excess of 20 kg]
Computed Value is in mL/day Ex. 25kg child Answer: 1500 + [100] = 1600cc/day
ATYPICAL DENGUE PNEUMONIA > MOT: -: extrpulmonary mosquito manifestations bite (man as reservior) -: low grade fever -: Vector: > patchy diffuse Aedes infiltrates aegypti -: poor response to Penicillin -: Factors > negativeaffecting sputum transmission: gram stain - breeding sites, high human population density, mobile viremic human beings Etiologic Agents Grouped by Age > Age incidence peaks at 4-6 yrs > Neonates (<1mo) > -Incubation GBS period: 4-6 days - E. coli > -Serotypes: other gram (-) bacilli --Streptococcus Type 2 – most pneumoniae common --Haemophilus Types 1& 3 influenza (Type B) - Type 4– least common but most severe > 1-3 months > *Main Febrile pathophysiologic pneumonia changes: a.- increase RSV in vascular permeability - Other respiratory ▼ viruses - extravasation Streptococcusofpneumoniae plasma - Haemophilus - hemoconcentration influenza (Type B) - 3rd spacing of fluids * Afebrile pneumonia b.- abnormal Chlamydiahemostasis trachomatis - -Mycoplasma vasculopathyhomilis - -CMV thrombocytopenia - coagulopathy
3 4 5
Breasts Preadolescent Breast & papilla elevated, as small mound, areola diameter increased Breast & areola enlarged, no contour separation Areola & papilla formed secondary mound Mature, nipple projects, areola part of general breast contour
Darker, beginning to curl, ▲amount Course, curly, abundant but amount < adult Adult, feminine triangle, spread to medial surface of thigh
SMR BOYS
HOLIDAY-SEGAR METHOD (MAINTENANCE) WEIGHT 0 - 10 kg 11- 20 kg > 20 kg
2
Pubic Hair Preadolescent Sparse, lightly pigmented, straight, medial border of labia
Stage 1 2 3 4 5
Pubic Hair None Scanty, long slightly pigmented Darker, starts to curl, small amount Resembles adult type but less in quantity, course, curly Adult distribution, spread to medial surface of thigh
Dengue Fever Syndrome (DFS) > 3-12 mo Biphasic - RSV fever (2-7 days) with 2 or more of the ff: - Other respiratory viruses 1. -headache Streptococcus pneumoniae 2. -myalgia Haemophilus or arthralgia influenzae (Type B) 3. -retroorbital C. trachomatis pain 4. -hemorrhagic M. pneumoniae manifestations -[petechiae, Group A Streptococcus purpura, (+) torniquet test] 5. leukopenia > 2-5 yrs - RSV Dengue Hemorrhagic Fever (DHF) - Other respiratory viruses 1. -fever, Streptococcus persistently pneumoniae high grade (2-7 days) 2. -hemorrhagic Haemophilusmanifestations influenzae (Type B) - -C. (+)trachomatis torniquet test - -M. petechiae, pneumoniae ecchymoses, purpura - -Group bleeding A Streptococcus from mucusa, GIT, puncture sites - -Staph melena, aureus hematemesis 3. Thrombocytopenia (< 100,000/mm3) 4. > 2-5 Hemoconcentration yrs - Streptococcus hematocrit >40% pneumoniae or rise of >20% from baseline - Haemophilus a drop in >20% influenzae Hct (from(Type baseline) B) following - C. volume trachomatis replacement - M. signs pneumoniae of plasma leakage - Group [pleuralAeffusion, Streptococcus ascites, hypoproteinemia] - Staph aureus
Penis Preadolescent Slightly enlargement
Testes Preadolescent Enlarged scrotum, pink texture altered
Longer
Larger
Larger, glans & breadth ▲ in size
Larger, scrotum dark
Adult size
Adult size
Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse 2. narrow pulse pressure (<20mmHg) 3. hypotension for age 4. cold, clammy skin & irritability / restlessness DANGER SIGNS OF DHF
DENGUE PATHOPHYSIOLOGY
< 15 kg, < 2 y/o > 15 kg, 2 y/o
MILD DEHYDRATION 50 cc/kg 30 cc/kg D5 0.3% in 6-8 hours
Stage 1
1. abdominal pain (intense & sustained) 2. persistent vomiting 3. abrupt change from fever to hypothermia with sweating 4. restlessness or somnolence Grading of Dengue Hemorrhagic Fever
MANAGEMENT OF DENGUE
MANAGEMENT OF HEMORRHAGE
A. Vital Signs and Laboratory Monitoring Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)
Torniquet Test: SBP + DBP = mean BP for 5 mins. ACUTE GLOMERULONEPHRITIS 2 Complications if ≥20 petechial of rash AGN per sq. inch on antecubital fossa -(+) CHF test2° to fluid overload - HPN encephalopathy -Herman’s ARF due Rash: to ê GFR - usually appears after fever lysed - initially appears on the lower extremities - not a common STAGES of AGN finding among dengue patients - Oliguric “an island phase of white [7-10days] in an ocean–ofcomplications red” sets in - Diuretic phase [7-10days] – recovery starts - Convalescent phase [7-10days] – patients are B. Secondary Prevention usually sent home Recommended Guidelines for Transfusion: Prognosis Transfuse: - Gross hematuria 2-3 weeks -- PC < 100,000 with signs of bleeding 3-6 weeks Proteinuria PC < 20,000 even if asymptomatic -- ▼C3 8-12 weeks use FFP if without overt bleeding -- microscopic hematuria 6-12 mo or - FWB in cases with overt bleeding or 1-2 years signs of hypovolemia - HPN 4-6 weeks C. Duration of Chemoprophylaxis > if PT & PTT are abnormal: FFP > PTT only: cryprecipitate > ifHyperkalemia may be seen due to Na+ retention > Ca++ decreases in PSAGN 3-7cc/kg/hr depending on the Hct (1st no.) level > ▲ in ASO titer (D5LR) - normal within 2 weeks 10-20cc/kg fast2drip PLR - hypotension, narrow pulse - peaks after weeks pressure pulse - more fair pronounced in pharyngeal infection than in cutaneous Leukopenia in dengue: probable etiology is Pseudomonas
URINARY RHEUMATIC TRACT FEVER INFECTION JONES CRITERIA: Suggestive UTI: A. - Pyuria: Major Manifestations WBC ≥ 5/HPF or 10mm3 - Absence - Carditisof pyuria doesn’t rule out UTI (50-60%) - Pyuria - Polyarthritis can be present w/o UTI (70%) - Chorea (15-20%) Presumptive - Erythema Marginatum UTI: (3%) - (-) - Subcutaneous urine culture Nodules (1%) - lower colony counts may be due to: B.*Minor overhydration Manifestations *- recent Arthralgia bladder emptying *- previous Fever antibiotic intake - Laboratory Findings of: Proven ▲ Acute or Confirmed Phase Reactants UTI: (ESR / CRP) - (+) urine Prolonged culturePR ≥ 100,000 interval cfu/mL urine of a single organism C. - multiple PLUS Supporting organisms inEvidence culture may of Antecedent indicate a contaminated Group-A Strep sample Infection - (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test
TREATMENT OF RHEUMATIC FEVER A. Antibiotic Therapy - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin *** NOTE:
Sumapen
= Oral Penicillin!
B. Anti-Inflammatory Therapy 1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks 2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days
PREVENTON A. Primary Prevention - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin
KAWASAKI DISEASE TYPES OF SEIZURES CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI A. Partial Seizures (Focal / Local) (ALL SHOULD BE PRESENT) – Simple Partial
–
A) HIGH Grade Partial Fever (>38.5 Rectally) PRESENT Complex (Partial Seizure + for AT LEAST 5-days without Explanation Impairedother Consciousness) “High Grade Fever of at least 5 days” Partial Seizures evolving Tonic-Clonic DOES NOT Respond to any to kind of Antibiotic! Convulsion B) Presence of 4 of the 5 Criteria 1. CONGESTION B. Bilateral Generalized Seizures of the Ocular Conjunctiva (seen in 94%) Absence mal) (At least ONE) 2. Changes of the Lips and (Petit Oral Cavity – Myoclonic 3. Changes of the Extremities (At least ONE) – Clonic 4. Polymorphous Exanthem (92%) – TonicAdenopathy = Non-Suppurative Cervical 5. Cervical – Tonic-Clonic Adenopathy (should be >1.5cm) in 42%) – Atonic HARADA Criteria - used to determine whether IVIg should be given SIMPLE FEBRILE SEIZURE - assessed within 9 days from onset of illness vs. 1. WBC > 12,000 COMPLEX FEBRILE SEIZURE 2. PC <350,000 3. CRP > 3+ Febrile Seizure: 4. Hct <35% “A seizure in association with a febrile illness in the g/dL or acute electrolyte absence of Albumin a CNS <3.5 infection 6. Age 12 imbalance in months children older than 1 month of age 7. Gender: male seizures” without prior afebrile
– –
5.
• •
IVIg is given if ≥ 4 of 7 are fulfilled If < 4 with continuing acute symptoms, risk score must be reassessed daily
CLASSIFICATION TREATMENT BY CAUSE
SIMPLE SEIZURES FEBRILE SEIZURE
A. Currently Acute Symptomatic Recommended Protocol: (shortly after an acute insult) A. –IV-Immunoglobulin Infection – Hypoglycemia, low sodium, low calcium –2g/kg Head Regimen trauma Infusion EQUALLY Effective in –Prevention Toxic ingestion of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation B. Remote Symptomatic as measured by days of Fever, – Pre-existing ESR, CRP,brain Platelet abnormality Count, Hgb, or insult and Albumin – Brain injury (head trauma, low oxygen) NOTE: – Meningitis There is a TIME FRAME of 10 days – Stroke – Tumor B. –Aspirin Developmental brain abnormality
A. Criteria for an SFS > Seizures: – sudden event 100.4 rectal to 101 F (38 to 38.4 C) > Epilepsy: – tendency for recurrent No recurrence seizures in 24 that hours are – unprovoked byNo anpost-ictal immediate neuro cause abnormalities (e.g. Todd’s paresis) > Status – epilepticus: >30min Most common or back-to-back 6 months to 5 years w/o return to baseline – Normal development > Etiology: – No CNS infection or prior - V ascular afebrile seizures : AVM, stroke, hemorrhage - I nfections : meningitis, encephalitis -B.T Risk raumatic Factors: - A utoimmune : SLE, vasculitis, ADEM Febrile seizure in 1st / 2nd - M etabolic : electrolyte imbalance degree relative - I diopathic : “idiopathic epilepsy” Neonatal nursery lesion stay of - N –eoplastic : space occupying >30 days : - S tructural cortical malformation, – Developmental delay prior stroke Height of temperature - S–yndrome : genetic disorder
C. HIGH Idiopathic Dose ASA (80-100mg/kg/day divided q 6h) should – No history be given ofInitially preceding in Conjunction insult with IV-IG – Likely “genetic” component THEN Reduced to Low Dose Aspirin (3-5mg/kg/day) AND Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease)
–
C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy) – Developmental delay – Complex FS (possibly > 1 complex feature) – 5% > 30 mins => _ of all childhood status – Family History of Epilepsy – Duration of fever
BRONCHIAL ASTHMA (GINA GUIDELINES)
Day symptoms Limitation of activities Nocturnal Sx (awakening) Need for reliever Lung function Exacerbation
Controlled
Partly Controlled
none
> 2x per wk
none
any
none
any
< 2x per wk
> 2x per wk
normal
< 80%
none
> 1x per yr
Uncontrolled
3 or more symptoms of Partly Controlled Asthma in any week
1x / week
Clinical Features: TUBERCULOSIS
RESPIRATORY DISTRESS SYNDROME (Hyaline Membrane Disease)
A. Pulmonary TB
– fully susceptible M. tuberculosis, – no history of previous anti-TB drugs – low local persistence of primary resistance to Isoniazid (H) ☤
2HRZ OD then 4HR OD or 3x/wk DOT
– Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary) – previous anti-TB use – close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H. –
☤ B.
2HRZ + E/S OD, then 4 HR + E/S OD or 3x/week DOT
2.
o Corticosteroids: • most successful method to induce fetal lung maturation • Administered 24-48 hours before delivery decrease incidence of RDS • Most effective before 34 weeks AOG
3.
o Microscopically: diffuse atelectasis, eosinophilic membrane Pathophysiology: 1.
Impaired/delayed surfactant synthesis & secretion
2.
V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance Hypoxemia and systemic hypoperfusion Respiratory and metabolic acidosis Pulmonary vasoconstriction Impaired endothelial &epithelial integrity
Extrapulmonary TB – Same in PTB
3. 4. 5. 6.
– For severe life threatening disease (e.g. miliary, meningitis, bone, etc)
7.
☤
2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT
1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting
o Male, preterm, low BW, maternal DM, & perinatal asphyxia
8.
Proteinous exudates RDS
Pallor – from anemia, peripheral vasoconstriction Onset – within 6 hours of life Peak severity – 2-3 days Recovery – 72 hours
Retractions: o Due to (-) intrapleural pressure produced by interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall Nasal flaring: o Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance Grunting: o Expiration through partially closed vocal cords
• •
Initial expiration: glottis closedà lungs w/ gasà inc. transpulmo P w/o airflow Last part of expiration: gas expelled against partially closed cords
Cyanosis: Central
– tongue & mnucosa (imp. Indicator of impaired gas exchange); depends on
UMBILICAL CATHERIZATION NEWBORN RESUSCITATION
• •
• • •
AIRWAY: Positioning Suctioning
open & clear
Endotracheal intubation (if necessary) BREATHING is spontaneous or assisted Tactile stimulation (drying, rubbing) Positive-pressure ventilation CIRCULATION of oxygenated blood is
adequate • Chest compressions • Medication and volume expansion
RESUSCITAION MEDICATIONS Atropine Bicarbonate Calcium Calcium chloride Calcium gluconate Dextrose Epinephrine
0.02 ml/k IM, IV, ET 1-2 meq/k 10 mg elem Ca/k slow IV 0.33/k (27 mg Ca/cc) 1 cc/k (9 mg Ca/cc) 1g/k = 2 cc/k D50 4 cc/k D25 0.01 cc/k IV, ET
Cathether length • Standardize Graph
Indications • Vascular access (UV) • Blood Pressure (UA) and blood gas monitoring in critically ill infants
– •
Complications • Infection • Bleeding • Hemorrhage • Perforation of vessel • Thrombosis w/ distal embolization
•
•
– – –
Ischemia or infarction of lower extremities, bowel or kidney Arrhythmia Air embolus
• •
Perpedicular line from the tip of the shoulder to the umbilicus Measure length from Xiphoid to umbilicus and add 0.5 to 1cm. Birth weight regression formula Low line
: UA catheter in cm = BW + 7
High line
: UA catheter
UV catheter length
= [3xBW] + 9 = [0.5xhigh line] + 1
Procedure • Determine the length of the catheter • Restrain infant and prep the area using sterile technique • Flush catheter with sterile saline solution • Place umbilical tape around the cord. Cut cord about 1.5-2cm from the skin. • Identify the blood vessels. (1thin=vein, 2thick=artery) • Grasp the catheter 1cm from the tip. Insert into the vein, aiming toward the feet. • Secure the catheter • Observe for possible complications
Cautions • Never for: – Omphalitis – Peritonitis • Contraindicated in – NEC – Intestinal hypoperfusion Line Placement • Arterial line • Low line – Tip lie above the bifurcation between L3 & L5 • High line – Tip is above the diaphram between T6 & T9
BILIRUBIN PRETERM: 0-1 hr 1-2 d 3-5 d
mg/dl 1-6 6-8 10-12
mmol/L 17-100 100-140 170-200
mg/dl 2-6 6-7 4-12 <1
mmol/L 34-100 100-120 70-200 <17
TERM 0-1 hr 1-2 d 3-5 d 1 mo
KRAMERS CLASSIFICATION OF JAUNDICE ZONE
JAUNDICE
I
Head & neck Upper trunk to umbilicus Lower trunk to thigh Arms, legs, below Hands & feet
II III IV V
SERUM BILIRUBIN 6-8 9-12 12-16 15 15
MKD COMPUTATION LUMBAR PUNCTURE •
the technique of using a needle to withdraw cerebrospinal fluid (CSF) from the spinal canal.
SPINE Procedure • spinal cord stops near L2 • Apply local anesthetic creambetween (ideally)L3-L4 or lower lumbar spine (usually • Position the patient L4–5) is preferable • Prepare the skin using sterile techniques •CSFAnesthetize the area with lidocane • clear, watery liquid that protects the central Puncture the skinfrom in the midline just caudal to the nervous system injury process, angle cephalad toward the • spinus cushions the brain from the surrounding bone. • umbilicus It contains:using a g23 needle • Collect the CSF for analysis glucose (sugar) CSF Analysis protein 1. Gram stain, culture and sensitivity – white blood cells count 2. Cell count, differential CLASSIFICATION BASED ON SEVERITY Rate :Chemistries 500ml/day or 0.35ml/min – sugar, protein 4. Special studies Range : 0.3-04 ml/min PERSISTENT INTERMITTENT MILD MODERATE After care : 50ml (infants) Volume • Cover the puncture site with a sterile bandage, Affects daily Affects daily 150ml (adults) apply pressure packing. Exacerbation Brief activity & activity & • Patients must remain lying down for 4-6 sleep hours sleep Indication •Day-time NPO for 4 hrs Sxs <1x/wk >1x/wk daily • to diagnose some malignancies (brain cancer and Nightime Sxs <2x/mo >2x/mo >1x/wk leukemia) PEFR >80% >80% 60 - <80% to assess patients with certain 20psychiatric PEFR VAR <20% - 30% >30% symptoms and conditions. FEV1 >80% >80% 60 - <80%
•
– –
•3. • •
• •
for injecting chemotherapy directly into the CSF
•
To diagnose other medical conditions such as: – viral and bacterial meningitis – syphilis, a sexually transmitted disease – bleeding around the brain and spinal cord – multiple sclerosis, (affects the myelin coating of the nerve fibers of the brain and spinal cord) – Guillain-Barré syndrome, (inflammation of the nerves)
Complication • Local pain • Infection • Bleeding • Spinal fluid leak • Hematoma (spinal subdural hematoma • Spinal headache • Acquired epidermal spinal cord tumor Caution & Contraindications • Increased ICP • Bleeding diasthesis • Traumatic Tap • Overlying skin infection • Unstable patient SEVERE Limits daily activity & sleep continuous frequent <60% >30% <60%
Breathless
Talks in Alertness RR Accessory muscles & retractions
Wt x mkd x preparation [mg/mL] = mL per dose e.g.
12kg x 10mg
x
5ml = 5mL per dose 120mg
* If per day, divide total (mL) by the # of divided doses Empirical dose 6 months ¼ tsp TID QID Dose x6 preparation mkd mos – 2 yrs x frequency½=tsp weight 2-6 1 tsp 6-9 1 ½ tsp 9-12 2 tsp
Paracetamol Drops
= Wt: move 1
decimal Age 1 2 CLINICAL FEATURES3 4 5SEVERE MILD MODERATE 6 - talking - INF: softer, 1 drop - at rest shorter, cry, - INF: stops 1 teaspoonful - walking difficulty 1 tablespoonful feeding - can lie down feeding 1 wineglassful - hunched - prefers 1 glassful forward sitting 1 grain sentences phrases 1 pint words may be usually 1 quart usually agitated agitated 1 ounce agitated often >30 1 Kg ▲ ▲ mins none
(+)
(+)
point to the left Wt 10 kg 12 14 16 18 RESPIRATORY ARREST 20 = 1/20 mL = 5 mL = 15 mLImminent = 60 mL = 2 ounces = 250 mL = 8 ounces = 60 mg = 500 mL drowsy / = 1000 mL = 30 mLconfused = 2.2 lbs bradypnea (+) thoracoabd movement