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Flashcards in pediatrics Deck (125)
1

most common peds emergencies and their tx

om-amoxicillin 80- 90mg/kg/d

Viral URI-acetaminofen, hold the cough syrup


acute gastro -oral hydration

2

fluid for shock

Boluses of 20ml/kg in shock

3

fluid for dehydration


Boluses of 10ml/kg in dehydration


Re-assess after each bolus

4

IOs can be done where? why would you

is coding

flat part of tibia and the humorous

5

what are the reasons physicians miss illness

wellness bias
pressure to be productive
desire to avoid avoid unnecessary or expensive tests.

6

temp greater than in Peds is a

i. Temp greater than 38C

7

Temp less than ___ correlates to a low risk for bacteremia.

Temp less than 39C (102.2 F) correlates to a low risk for bacteremia.

8

common sites of fever for a pediatric patient include (4)

a. Otitis Media
b. Pharyngitis-URI
c. Pneumonia
d. Acute Gastro-enteritis

9

when assessing toxic appearance in a ped (4)

pale-check mucosa

poor profusion
-a. Cyanosis, mottled skin

respiratory distress-
a. Tachypnea, shallow breathing


altered mental status
-a. Poor eye contact, feeding, failure to respond to caregivers.

10

Neonates, age 0-28 days w/ fever 38c or more

what's the workup (6)

i. Admit them all. Let the pediatrician sort them out.

1. CBC
2. Blood cultures
3. Urinalysis
4. Urine culture
5. Lumbar puncture
6. Parenteral antibiotics

11

when would you do a CXR in a admitted neonate

a. Cough
b. Tachypnea
c. O2 sat less than 95%

12

when woudl you do stool studies in a neonate

2. Stool studies if diarrhea

13

Fever, age 28-90 days work up for a child with a fever

i. CBC
ii. Urinalysis, gram stain if available
iii. Urine culture
iv. Blood culture

14

what would you want to consider in a 28-90 day work up for a child with a fever

1. Lumbar puncture, (some authors say all patients in this category)
2. Chest x-ray
3. Stool studies
4. Fecal leucocyte count and stool culture

15

Fever without a source: who can go home is based on

Rochester criteria
for bacteremia risk in infants 28-90 days old, with fever

16

Overall risk of occult bacteremia in well appearing febrile infant

1. Overall risk of occult bacteremia in well appearing febrile infant: 7-9%

2. If all Rochester Criteria met, risk is less than 1%

17

labs associated with rochester criteria

a. WBC 5-15k; bands less than 1.5k

b. Urine less that 10wbc/hpf, or neg leukocyte esterase/nitrate or negative gram stain of unspun urine

c. Fecal smear less than 5wbc/hpf

18

If reliable caregivers and access to follow-up in office or ED for 28-90 day old infant

a. Blood culture
b. Urine culture
c. Consider LP and ceftriaxone 50mg/kg IV
d. Re-evaluate in 24 hours
e. Admit positive blood culture or febrile UTI
f. Treat afebrile UTI as outpatient.

19

3-36 months oldFever without source-


1. Occult UTI

what sxs is associated with a higher risk of UTI

a. 2% of FWS in children under 5yrs

b. 6-8% of girls; 2-3% of boys under 12mo

c. Higher temp correlates with increased likely hood of UTI

20

Untreated UTI can lead

to kidney damage and renal failure in adulthood

21

3-36 months oldFever without source-

what would you suspect

occult UTI
occult PNA
occult bacteremia

22

what reduces the likelihood of occult PNA

b. Heptavalent pneumococcal vaccine reduces likelihood of pneumonia

23

what is the major signs of PNA

tachypnea

Positive x-ray in 26% of children with temp >39C or wbc>20k

24

3% of cases of Pneumococcal bacteremia progress to

meningitis

25

3-36 mo with toxic apperance workup

a. Admit
b. Septic work-up
c. IV antibiotics

26

Non toxic, Temp <39c 3-36 mo workup

a. No tests
b. Acetaminofen
c. Return if fever persists >48 hours or if condition deteriorates.

27

Nontoxic with temp> 39 C

when would you evaluate Urine

Evaluate urine for

all females < 12 months old;

uncircumcised males < 12 months old

circumcised males < 6 months old.

b. If UTI is found: culture urine, treat with antibiotics and and follow up in 48 hours.

28

when would you get a CXR in a non toxic kid wiht a temp >39

Chest x-ray if O2 sat < 95%,
tachypnea, rales, temperature

≥39.5°C and WBC count ≥20,000

29

febrile seizures are usually lesss than

Generalized seizure, less than 15 minutes duration associated with fever spike

30

is there a risk of epilepsy in kids with febrile seizures

2.4% risk of epilepsy by age 25, double average risk

31

Invasive infection of the subarachnoid space

Meningitis (can cause fever and seizures)

32

how does meningitis occur

usually by hematogenous spread from the upper respiratiory tract,

or direct inoculation from sinusitis,

mastoidits or otitis media or skull fracture

33

The younger the child, the _____ likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.

1. The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.

34

Neonatal meningitis associated with

Neonatal meningitis associated with maternal infection or pyrexia at delivery

35

Younger than 3 months, nonspecific symptoms of meningitis include

Younger than 3 months, nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high pitched cry, or seizures

36

Meningismus and a bulging fontanel may be observed but are not needed for diagnosis

as well as ____ irritability

paradoxical

child is irritated wehn you touch them

37

after 3 mos of age typical sxs associated with meningitis include

a. Fever
b. Vomiting
c. Irritability
d. lethargy, or any change in behavior

38

2-3 yrs of age typical sxs associated with meningitis include

a. headache
b. stiff neck
c. photophobia
d. Course may be brief and fulminant ( N. meningitidis) or gradual

39

in young infants with meningitis sxs are

a. specific findings are rare
b. May be febrile or hypothermic
c. Bulging fontanelle, diastasis of skull sutures, nuchal rigidity are late signs.

40

toddlers and children with meningitis usally present like

a. Meningeal signs
b. headache
c. nuchal rigidity
d. positive Kernig or Brudzinski's sign
e. Focal neurological signs
f. Seizures in 30% of cases
g. Obtundation or coma in 15-20%
h. Petechial-purpuric rash

41

Petechial-purpuric rash is usually

(found with Neiserria meningitis)

non blanching
i. < 3mm red spots that don’t blanch when compressed

42

labs for meningitis

1. Complete blood count (CBC) with differential
2. Blood cultures
3. Coagulation studies
4. Serum glucose
5. Erythrocyte sedimentation rate (ESR)
6. Electrolytes
7. Serum and urine osmolalities
8. Bacterial antigen studies can be performed on urine and serum. They are mostly useful in cases of pretreated meningitis

43

why are head CTs done for meningitis

a. Focal neurological signs
b. To rule out other pathology
c. Does not rule out increased intracranial pressure

44

how should the patient be positioned for a LP

knees are lined up directly and directly vertical

shoulders lined up

hyper flex

advance needle slowly without the stylette

45

what are you looking for in a LP of a child suspected of having meninigitis

a. Measure opening pressure
b. Cell count
c. Gram stain
d. Culture and sensitivity
e. Glucose
f. Protein and antigen
g. Acid-fast bacillus
h. Fungal stains

46

age range of epiglottitis

ii. Age range 1-6 years

47

history of epiglottitis


1. Acute onset of fever and sore throat
2. Dysphagia
3. Distress
4. Drooling
5. Cough is rare

48

Exam of epiglottitis

1. toxic appearing
2. Sniffing position
3. Muffled voice
4. Stridor
5. Lymphadenopathy

49

what to do if you think it is epiglottitis

DO NOT STICK A TONGUE DEPRESSOR IN AND LOOK IN THEIR EFFIN THROAT


1. Intubate in OR
2. Admit to ICU
3. IV abx
4. Steroids not proven

50

late signs of epiglottitis

Oximetry, hypoxia and cyanosis are late signs.

51

other respiratory issues you see commonly in winter

age range

croup

with noisy audible breathing

ii. Age range: usually 3 months- 3years

52

airway managrement for epiglottitis and tx

assemble a team that can manage airway

1. Fiberoptic naso-tracheal intubation, in the OR
2. Rapid Sequence Intubation, orotracheal, in the ER
3. Needle crico-thyrotomy if intubation fails
4. Long slow breaths if bag valve mask used prior to intubation

3. Disposition
4. Intubate in OR
5. Admit to ICU
6. IV abx
7. Steroids not proven

53

hx seen with croup

1. Gradual onset of URI symptoms
2. Rhinorrhea
3. Cough, barking like a seal
4. Fever
5. Stridor, often resolves by time of ED presentation.

54

exam with croup

1. Generally non toxic
2. May be playful and cooperative or restless and anxious
3. Stridor: inspiratory > expiratory

55

treatment for croup

1. Cool mist
2. Racemic epinephrine
3. Dexamethasone 0.6mg kg IM or PO (same efficacy), some authors recomend repeat dose in 6 hrs.
4. Nebulized Budesonide

56

Consultation/Admission, consider Intubation if for croup if

1. Hypoxia, cyanosis
2. Retractions unrelieved by initial treatment
3. Diminished breath sounds, diminished stridor
4. Change in mental status

57

home care for croup

1. Tobacco/irritant free environment
2. Vaporizer
3. Cool night air
4. Antipyrexia

58

RPA

Retropharyngeal abscess

Bacterial infection of retropharyngeal space leads to abscess formation and airway obstruction

59

what are we concerned abotu with RPA

ii. Can progress to mediastinitis (50% mortality), pericarditis, jugular vein thrombosis, carotid artery erosion, sepsis.

60

Hx of the patient with RPA

1. Sore throat
2. Odynophagia
3. Fever
4. Neck stiffness
5. Neck swelling (97% in infants)
6. Cough (33% in in infants)

61

exam findings with RPA

1. Neck mass (91%)
2. Cervical adenopathy (83%)
3. Fever (86%)
4. Neck stiffness (59%)
5. Retropharyngeal bulge (43% - do not palpate in children)
6. Agitation (43%)
7. Lethargy (42%)
8. Drooling (22%)
9. Torticollis (18%)
10. Respiratory distress (4%)
11. Stridor (3%)

62

tx for RPA

1. Admission/Consultation
2. IV abx
3. Intubate if respiratory distress
4. ENT will decide wether to I&D (in OR) or not

63

Retropharyngeal space should measure

6 at 2 and 22 at 6

look at these XRAYS

64

flat faced coin on CXR

esophagus

trachea rings trap it like thi

65

Coins that fail to pass into the stomach can be removed

by a foley catheter under fluroscopy, or by endoscopy

66

why are button batteries bad

will short out and erode through tissues

67

neonates suspected of PNA

1. grunting, flaring nostrils, tachypnea, and retractions

2. lethargy, poor feeding, or irritability

3. Cough is rare

4. Fever may be absent (may be hypothermic)


DO NOT COUGH

68

this type of PNA is most commonly seen 24 hrs after birth

Beta Strep likely if within 24 hours of birth

69

this type of PNA is most commonly seen in the 2nd or 3rd week of life

Chlamydia pneumonia with conjunctivitis in 2nd or 3rd week

70

Infants PNA presentation

1. Cough
2. Preceding URI
3. grunting, flaring, tachypnea, retractions
4. lethargy; poor feeding; or irritability
5. Bacterial, usually feberile

71

infants sxs of PNA

1. Cough
2. Preceding URI
3. grunting, flaring, tachypnea, retractions
4. lethargy; poor feeding; or irritability
5. Bacterial, usually feberile

72

toddlers and small children have these sxs with PNA

1. Cough
2. Preceding URI
3. Vomiting (post-tussive emesis)
4. Abdominal pain
5. Fever

73

sxs and pathogens in children with PNA

1. Atypical pathogens, Mycoplasma, more common


2. May have other constitutional symptoms such as headache and pleuritic chest pain

74

boiling in the chest

bronchitis

astham like at the bronchioles

75

hx of a pt with bornchitis

1. Preceding URI
2. Fever
3. Increased work of breathing
4. Vomiting, especially post-tussive
5. Irritability
6. Poor feeding or anorexia

76

increased work of breathing in a child with bronchitis most commonly looks like

a. Wheezing
b. Cyanosis
c. Grunting
d. Noisy breathing

77

exam for bronchitis can look like

1. Tachypnea, up to 50-60 breaths per minute (most common physical sign)
2. Tachycardia
3. Fever, usually in the range of 38.5- 39°C
4. Mild conjunctivitis or pharyngitis
5. Diffuse expiratory wheezing
6. Nasal flaring, intercostal retractions
7. Cyanosis
8. Inspiratory crackles
9. Otitis media
10. Apnea, especially in infants younger than 6 weeks
11. Palpable liver and spleen from hyperinflation of the lungs and consequent depression of the diaphragm

78

labs for bronchiolitis

1. CBC: seldom useful
2. Urine specific gravity: possible dehydration.
3. Serum chemistries: gauging severity of dehydration.
4. ABG may be needed in the severely ill patients
5. Specific viral test for RSV helps confirm diagnosis but not essential.

79

CXR fir bronchiolitis can look like

1. Hyperinflation and patchy infiltrates may be seen.
These findings are nonspecific and may be observed in asthma, viral or atypical pneumonia, and aspiration.
2. Focal atelectasis
3. Air trapping
4. Flattened diaphragm
5. Increased anteroposterior diameter
6. Peribronchial cuffing

80

why would you get a CXR for bronchiolitis

ay also reveal evidence of alternative diagnoses, such as lobar pneumonia, congestive heart failure, or foreign body aspiration.

81

TX for bronchiolitis

1. Pulse oximetry monitoring
2. Respiratory support
3. O2, cool mist
4. Nasal suction = best tx
5. Supportive care
6. Comfort
7. Hydration
8. Antipyrexia, analgesia

82

admissions criteria for bronchiolitis

1. Oxygen saturation less than 94% after therapy. Some say less than 92%
2. Respiratory distress (eg. respiratory rate >60/min or retractions at rest)
3. Apnea or risk of apnea
4. Age younger than 2 months or history of prematurity
5. Underlying cardiopulmonary disease or immunosuppression

83

signs of resp distress in children

i. Grunting
ii. Flaring
iii. Severe tachypnea
iv. Retractions
v. Low O2 saturation
vi. Severe distress not responsive to supplemental O2?
1. Get help and prepare to intubate

84

signs of pyloric stenosis

i. History
1. Occurs by 3rd week of life
2. Projectile vomiting after feeding
3. Hungry
4. Failure to gain weight
5. Progresses to dehydration
ii. Hypochloremic, hypokalemic metabolic alkalosis.

85

PE with pyloric stenosis

1. Signs of dehydration(hyprochloremic hypokalemic metabolic acidosis.)

2. Palpable “olive” near lateral edge of right rectus, inferior to liver, is diagnostic

3. Ultrasound if “olive” not palpated (20% false negative)

4. Barium swallow

86

i. Most common cause of intestinal obstruction age 3mo-6yrs

b. Intussusception

87

who gets intussusception

ii. male:female = 4:1

88

sxs of intussusception

iii. Episodic abdominal pain, increasing severity and frequency
iv. Currant jelly stools in 50% (dark yellow)

89

i. Acute onset of billius vomiting, distension, pain.

c. Midgut volvulus

bilious vomit it the key here

90

c. Midgut volvulus most commonly seen

ii. 50% in 1st month; 90% in first year

91

Plain films may see “coffee bean sign” or “birds beak”, likely need this

midgut vovulus
ct or crontrast study

Surgery is needed emergently as bowel becomes ischemic, necrotic and perforates.

92

Infantile colic

i. Infant that feeds normally has episodes of crying and drawing up legs.
ii. Parents will attribute to abdomen but pt without vomiting or diarrhea

93

Infantile colic usually resolves by

iii. Usually resolves by 10 weeks. Look for other causes: abuse, constipation,volvulus,corneal abrasion, hair tournequet, GERD or anal fissures.

94

IT CRIES

b. Infection - any kind (look for fever, infectious sx)

c. Trauma - including abuse (know your infant milestones)

d. Cardiac - SVT, sweating with feeds, FTT, poor feeding

e. Reflux & Reaction to meds

f. Immunization site & Intussisception

g. Eyes - corneal abrasions (do fluorescein staining)

h. Strangulation/Surgical causes - hair tourniquets, torsion, intussisception (check the fingers/toes, take off the diaper)

95

presentation

1. Anorexia, vomiting
2. Periumbilical pain, migrates to RLQ, becomes diffuse after rupture
3. Limp
4. RLQ tenderness and peritoneal signs
5. Leukocytosis, ketonuria
iv. Pitfalls
1. Pt may have normal WBC count

96

d. Torus fx

review XRAYS

needs to be immobilized

97

part of the cortex remains intact in this type of pediatric fx

e. Greenstick fx

98

we have a _____ threshold for ordering x- rays than adults

lower threshold

99

nursemades elbow is also knwon as

subluxation of the radial head

100

how does a nursemades elbow occur

i. Caused by distraction of the arm in extension

101

children with a nursemades will present with

iv. Refuses to use injured arm
v. Held in pronation, and extension

102

would you need imaging in a nursemaids elbow

vii. Imaging is not needed if history and exam is typical

if no one saw what happened

viii. X ray tech likely to reduce while positioning for film

103

how to fix a nursemades elbow

thumb on radial head supinate and pull it up

104

if the class method does not work

keep it pronate and pop it up

105

g. Slipped Capital Femoral Epiphysis seen most commonly in this population

Age 12-15 in boys,

10-13 in girls

often heavy but not always

106

pain seen with

slipped Capital Femoral Epiphysis

iii. Presents with hip and groin pain, knee pain

iv. Abnormal gait, external rotation

107

kids with SCFE can't

v. Unable to press thigh against abdomen

108

XRAY for SCFE

scoop of ice cream fallen off the cone lOOK CLOSE

like you are about the shave off the grater trochanter from the head of the femur
should come up to the line

109

mangement of a SCFE

1. Admission
2. Consultation
3. Absolute non-weight bearing
4. Surgery

110

Transient Tenosyovitis of the Hip is seen as


1. Acute or gradual onset of abnormal gait

111

Transient Tenosyovitis of the Hip seen in what population

2. Under 10 years old

112

pain associated with Transient Tenosyovitis of the Hip

3. Hip, thigh and knee pain
4. Tenderness over anterior hip

113

lab diagnostics associated with Transient Tenosyovitis of the Hip


5. X-rays normal or show hip joint effusion
6. Normal or slightly high wbc and esr


r

114

how to handle scrotum in zipper

cut zipper at open end with clippers

115

tx for transient Tenosyovitis of the Hip

7. Supportive treatment and re eval in 2 weeks

116

septic joint seen with

ii. Septic joint
1. Esr>20, CRP >2mg/dl, wbc>12
2. Non weight bearing
3. Fever

117

occult bacteremia in a child 3-6 months

what can pnumococcal bactermia progress to

a. FWS with temp 39.5 (103.1f)
b. Positive blood culture in <1% if WBC <15k
c. Positive blood culture in 10% if WBC > 15k


3% of cases of Pneumococcal bacteremia progress to meningitis

118

what is effective prevention of pneumococcal disease

Heptavalent pneumococcal vaccine, Prevnar, is effective in preventing invasive pneumococcal disease.

119

signs of dehydration

hyprochloremic hypokalemic metabolic acidosis.)

120

normal VS for infant

30-50 RR

120-160 hr

121

normal VS infant

20-40 RR

80-140 HR

122

Occult bacteremia (kid has a fever but you can’t find it)

what pathogens would you suspect in infants

a. H. influenzae type b
b. N. meningitidis
c. S. pneumoniae

123

Occult bacteremia (kid has a fever but you can’t find it)
what pathogens would you suspect in older children

a. N. meningitidis
b. Group A beta hemolytic Strep.

124

PE findings with bacteremia

No consistantly present findings on history or exam, except for fever.

Temp <39C --> low likelihood of positive blood cultures.

125

sxs of tracheobronchial Foreign Bodies

i. 50% show air trapping
ii. 12% atelectasis
iii. 18% signs of infection
iv. 24% normal
v. Suspected Respiratory FB may need CT or bronchoscopy to confirm the dx