Pedia tickler

BODY TEMPERATURE Subnormal Normal Subfebrile Fever High fever Hyperpyrexia

ABG

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 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 (14 days, non-infectious causes

Persistent

: >14 days, infectious cause

ORS vol. after each loose stool 1 day 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

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( 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 ( -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 ( 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 3+ Febrile Seizure: 4. Hct 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 80% >80% 60 - 80% >80% 60 -