Download Norske lysark 2001

Summary in pediatrics
IIC/D 2016
• Infections
– Congenital heart disease
– main groups
– Murmurs
– Chronic heart failure –
signs and symptoms
– Acute heart disease –
ductus dependent
disease
– Cardiac arrest and
resuscitation
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General
Airway
Breathing
Circulation
Disability
Abdomen
ENT
Looking for a focus
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• Cardiology
Henrik Døllner
Barne- og ungdomsklinikken
St. Olavs hospital
LBK-NTNU
The acute ill child: Initial
Examination
• Emergency pediatrics
– Lower RTI
• Asthma treatment
– Sepsis and meningitis
– Cramps
– Vomiting
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Clinical examination and evaluation
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General
– Behavior –
normal/lively/irritable/
lethargic
– Colour
– Temperature
Airway
– Stridor
– Noisy breathing
– Drooling
Breathing
– Recessions/accesory
muscles
– Respiratory rate
– Auscultation
– Oxygen saturations
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Circulation
– Peripheral temperature and
colour
– Pulse
– Capillary refill time
– Blood pressure
Disability
– Alert
– Voice only
– Pain only
– Unresponsive
Abdomen
– Tendernes
– Tumors
ENT
– Ears and throat
Looking for a focus
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Looking for a focus
Acute diseases
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• Severe infections (meningitis/sepsis
etc)
• Severe respiratory failure
(obstructive, hypoxic)
• Status epilepticus
• Intussusception, other acute
gastrointestinal conditions
• Anaphylaxis
• Acute heart failure
• Dehydration and imbalanced fluid
and electrolyte balance
• Injuries, intoxication
Neck- and/or backstiffness: meningitis?
Rash: DIC and meningococcemia?
Limp: fracture? Osteomyelitis?
Abdominal tendernes: appendicitis?
Abdominal tumor: intususception?
Pain: could be a lot off things
Difficulty swallowing: foreign body?
etc
etc
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Examination
Resuscitation
Anafylaksia
Dehydration
Respiratory failure
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• FEVER
• Respiratory problems
• Cramps
• Vomiting (evt green)
• Circulatory failure,
hypotension
• Lowered
consciousness
Who shall be hospitalized?
Sepsis: systemic response
to infection
• Grade of respiratory failure most important,
independent of etiology!
• Treatment before admission
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Oxygen
Inhalation (adrenalin, B2-agonist)
Adrenaline s.c.
Steroids i.m. / p.o. (long transport time)
• Consider transport possibilities
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Sepsis - mechanisms
• Hypovolemia
• Decreased
perfusion to
tissues and
organs (kidney,
liver, lungs,
bowel)
• HYPOXIA and
organ damage
– Capillary leak
– Vasodilatation
• Decreased
myocardial
function
• Hypotension and
shock
SEPSIS IN CHILDREN
INITIAL TREATMENT
• Oxygen
• Fluids - volume
– Isotonic NaCl/Ringer: 10 – 20 ml/kg (10-30 min)
– Repeat (several times) untill response
• Antibiotics i.v. (first choice)
– Ampicillin + aminoglycosides
– Other - supplemental
• Metronidazol (anaerobic infections, intestinal perforations, abcesses)
• Cloxacillin (S. aureus)
• Intensive care and observation
– Circulation
– Respiration
– Mental condition
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Sepsis – behandling (første)
MENINGITIS IN CHILDREN
• Oksygen nasalt
• Væske/volum
 Newborns and infants
– Isotonisk NaCl/Ringer – 10 – 20 ml/kg (10-30 min)
– Gjentas (flere ganger) inntil respons
• Antibiotika i.v. (1. valg)
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ampicillin 50 mg/kg x 4-6 + gentamicin 7 mg/kg x 1
Evt metronidazol
Evt kloxacillin
Evt klindamycin
Obs doser litt annerledes <1 måneds alder
• Intensiv overvåking og behandling
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Symptoms and findings
 Listless, don’t eat well, irritable, vomiting, no interest of
the surroundings
 Reduced general condition, pale, reduced level of
consciousness, bulging fontanelle, neck stiffness +/- fever
 Children
 Fever, headache, nausea and vomiting, cramps, light
sensitive, musclepains, bonepains
 Pale, neck stiffness, back stiffness, confusion and
increasing loss of consciousness and poor general
condition
 Everybody
 Rash
 Purpuric rash (pettechial), and eccymoses (meningococcal
disease)
 others
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MENINGITIS IN CHILDREN
Treatment
Rhinitt
– Age <3 months: Ampicillin + cefotaxime
– Age >3 months: Cefotaxime
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Ørebetennelse
Forkjølelse
• Antibiotics
Halsbetennelse
Falsk krupp
Prophylactic steroids (Pn.c., HiB)
Fluids (basal volum)
Good oxygen saturation
Close observation
Nedre luftveisinfeksjon
– Mental level, breathing, seizures
• Isolation 24 hrs (Transmission via droplets)
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Lower respiratory tract infections
-classification in children
Bronchiolitis (viral) – newborns/infants age 0-2 y
• Very common
• Takypnea +/- Wheezing (bilateral)
• Stet p: Crepitations bilaterally +/- prolonged exspiration/rhonchi
• Bronchitis (viral) – from age 1-2 year
• Obstructive – very commen in children
• Wheezing (bilateral)
• Stet p: Prolonged expiration and rhonchi
• Non-obstructive -less common
• Astma bronchiale (viral, allergy, cold, exertion)
• Viral astma attacks – very common
• Definition a: 3 episodes with bronchopulmonary obstruction (BPO)
• Definition b: 1 BPO episode and atopia (eczema)
• Wheezing (bilateral)
• Prolonged expiration and rhonchi
All have general signs of respiratory difficulty:
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Lower respiratory tract infections
-classification in children
• Pneumonia
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Viral – common
Bacterial – all ages
Mycoplasma – particularly from age 5 years
Mixed or complicated viral-bacterial – quite seldom
Takypnea, cough, lethargic
Stet p: Maybe crepitations/decreased sounds – often unilateral/locally
General signs of respiratory difficulty
• Chronic lung disease with acute infection
• CF, bronchiectasia, bronchopulmonary dysplasia, others
• Signs: varying
• Pseudocroup (acute laryngitis) (viral)
• Stridor (inspiratory)
• Stet p: normal (transmitted sounds)(rhonchi)
– Takypnea, inndrawings, nasal flaring, use of accesory muscles etc
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Lower RTI/pneumonia: Who do not
need antibiotics?
Ødem/hevelse
Slimplugging
Airtrapping
Hvesing/takypnø
1. Age > 3 months
2. Full basis vaccination
3. No pre-disposing comorbidity
4. Disease duration >24 timer
5. Particularly if wheezing (BPO)
6. CRP <50-100 mg/L and WBC <12–15
7. No lobar or large infiltrates
8. Positiv virus findings, i.e. RSV
If 1-6 (and evt. 7-8) are present: antibiotics unlikely to work
But follow-up is important
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Respiratory problems
Acute asthma attack: treatment
• Oxygen
• Terbutalin
• Fast breathing
• Measure SAT O2
– 0,1-0.2 mg/kg in saline inhalation (repeated)
– Pale (grey, cyanotisc = late sign!!!!)
• Heavy breathing - listen, auscultate
– Inspiratory?
• Inspiratory stridor = upper airway obstruction (i.e.
pseudocroup)
– Expiratory?
• Lower RTI (obstructive bronchitis, bronchiolitis, asthma)
• Often combined with prolonged expirium
• Obs: «Silent chest» - no ventilation
• Signs of respiratory failure: Indrawings / nasal
flare
• Grunting (obs: pneumonia evt bronchiolitis)
• Adrenalin 10 microgram/kg i.m.
Hospital, in addition
• (Rasemic) adrenaline inhalation
• Frequent terbutalin inhalations +/- ipratropium
• Theophyllin i.v.
• Terbutalin i.v.
• Steroids (hydrocotison 50 -100 mg i.v.,
dexametason/prednisolon p.o.)
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Congenital heart disease – main groups
• Shunts
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Main clinic
VSD (Ventricle-septumdefect, most muscular) Primary asympt.
ASD (Atrieseptumdefekt, most: secundum)
Grade of L-R shunt:
AVSD (Atrioventricularseptum defect)
Heart failure?
PDA (Persisterende ductus arteriosus)
• Obstructions
– HVHS (Hypoplastic left-ventricle syndrome)
- AS (Aortic stenosis)
- PS Pulmonary stenosis
– Coarctatio aorta
• Cyanotic heart diseases
– TGA (transposition of big vessels): Duct dependant!
– Fallots tetralogy
• (PS, HVH, overriding aorta, VSD)
Grade of obstruction
Duct dependant
+/-Heart failure
+/-Cyanosis
Duct dependant?
Primary cyanosis/duct
dependant
1) Duct dependant?
2) Cyanotic spells etc;
heart failure only if
shunt
Murmurs
• Physiological
– Systolic: Left sternal edge, grade 1-3, ejection, lair
dependant
– «Venesus»: Over deep neck vesssels, continous, lair
dependant
• Patologic murmur is suspect if
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Holosystolic
Diastolic
Strong murmurs, gr. 3-6
Constantly slit 2. tone (ASD)
Emission to the back
Fremissement
Weak or missing femoral pulse
Non-lair dependant
Symptoms and signs of heart disease (Downs syndrom,
other congenital malformations)
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Chronic heart failure
Duct dependant heart diseases
Symptoms
• TGA, coartatio aortae, HVHS, Fallot etc
• Postnatal asymptomatic
• Acute sirculatory collaps develops 1-2 weeks after
birth when the duct closes
• Fast development (hours)
Treatment
• Less blood to the body:
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– pale, prolonged capillary
refill time
• Increased blood in the
lungs:
– Takypnea (during exercise
i.e. eating), evt cyanosis
• Increased blood in liver:
– Hepatomegalia
– (peripheral oedema rare)
• Increased energy
demands:
– growth failure
– poor weight gain
Oxygen
ACE-inhibitors
Diuretics
Betablokkers
Digoxin
Reinforced nutrition evt by
tube
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Wont eat
Lethergic
Pale  grey  blue
Cold, prolonged cap. refilltime
Takypnea / takycardia
• Differential diagnosis: Septicaemia
• General condition poor
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Cardiac arrest in children
Resuscitation in children
• Nearly always due to respiratory failure
• Evt arrytmia
– VF and VT seldom
– SVT = Supraventrikulær takykardi
• Puls > 200-250/minute
• Failure after hours/days (but seldom cause of arrest)
• Obs: Delta wave (WPW syndrome)
– Secondary to
• A known heart malformation or surgery
– Increase intrathoracic pressure/stimulate nerve
system
– Adenosin i.v.
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The child in shock: Acute failure
of circulatory function
• Hypovolemic shock : Hemorrhage,
gastrointestinal losses, renal losses, burns
• Maldistribution: Sepsis, asphyxia,
anaphylaxis, intoxication, acute spinal
damage, nephrotic syndrome
• Cardiogenic shock: Cardiac failure,
arrhythmias, cardiomyopathies,
pneumothorax
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DEHYDRATION –
CLINICAL CONDITIONS
• Infections
– Gastroenteritis (external losses)
– Sepsis (internal losses – compartment shift)
• Gastrointenstinal emergencies
Intussusception (“invaginasjon”) (1-4/1000
children)
– Ileus – appendicitis- other causes (ex. previous GI
surgery)
• Congenital malformations
– Pyloric stenosis (3/1000 children)
– Other intestinal atresia, stenosis and malrotations
(1:1500)
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SUSPECTED DEHYDRATION
EMERGENCY ASSESSMENTS
• Degree of dehydration?
• Need for hospitalization?
• Oral or intravenous therapy?
• Assessment of initial rescue therapy
Acute weight loss = loss of body
fluid
(stated in % of body weight) (X g = X ml
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ESTIMATION OF DEGREE OF
DEHYDRATION
Mild (~ 5%):
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(5% = 50 mL/kg)
Thirsty, reduced urine output, normal respiration and
heart rate
Pale, sunken eyes, sunken anterior fontanel, (reduced
skin elasticity)
Moderate (~10%):
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(10% = 100 mL/kg)
+ Limp, lethargic
Reduced capillary refill (>3’’), usually not thirsty, tachycardic,
respiration deep, marked oliguric, dry mucous membranes
Severe (~15%):
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(15% = 150 mL/kg)
+ Reduced conciousness or comatose, respiration deep
and rapid, cyanotic, low BP
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Signs of dehydration
NEED FOR HOSPITALIZATION?
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• All - if more than mild/moderate
dehydration (≥5%)
• Especially if < 1 year
• Especially if on-going vomiting
• Allways if suspicion of serious
underlying disease (sepsis,
gastrointestinal obstruction)
Hypotension is a late and serious sign
Pulse: Frequency
and volume
Capillary refill time
Skin temperature low and color (pale)
Urinary output: Expect >1-2 mL/kg/hour
Breathing tachypnoe
Mental status: Agitation, drowsiness
Blood gas: Lactate and base deficit
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MILD TO MODERATE DEHYDRATION (< 5%)
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ORAL REHYDRATION
MODERATE TO SEVERE DEHYDRATION
ADVICES FOR CARETAKERS AT HOME
• Saline (Nacl 0.9%) or Ringer acetate: 10-20
mL/kg to RAPIDLY EXPAND ECF VOLUME
is safe and preferable in all, - as a first try
– Small (portions) and frequent (administration)!
– Breastfeeding should be maintained!
– Oral rehydration solutions: Glucose + Sodium
• Glucose facilitates intestinal reabsorption
• Ex. Mineral water, meat broth, clear soup + soda, juice, syrup
• Ex. GEM or RESORB - Glucose-electrolyte mixture (from pharmacies)
Na+ 50, K+ 20, Cl- 40, citrate 10 mmol/L (in developed countries – more salt in
developing countries)
– By spoon, syringe or small sips to prevent more vomit
GIVE: as long as vomiting/diarrhoea continues
AFTER SYMPTOMS HAVE SUBSIDED, normal diet can be
reintroduced immediately (no need to avoid milk or advice special
diets)
- INITIAL RESCUE REHYDRATION
• Infusion time: From 10-15 minutes to 1-2 hours
(depending on the severity of symptoms)
CAN BE REPEATED (up to 40 mL/kg) and used in
ALL CLINICAL SITUATIONS
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ANAPHYLAXIS
Vomiting WITHOUT diarrhea
Symptoms
• Is NOT gastroenteritis (enterites = diarrhea)
• Gastrointestinal obstruction
– Pylorusstenosis, intususception, strangulation
ileus
– Adherance-ileus (previous surgery), malrotation
• OBS other sevre conditions
– (meningitis/tumor-hemoragia cerebri, DM, etc)
= Emergency help needed: Acute abdomen
(surgery)
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• Urticaria
• Angioneurotic oedema
• Asthma
• Pale, dizzyness, syncope
→ Sirculatory failure
Etiology
• Insect bite
• Food (nuts, kiwi, others)
• Medications (penicillin)
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Treatment
• Notify!
• ADRENALIN sc/iv/inhal.
– Antihistamine po
– Hydrocortison im
– Evt Beta2-agonist
• Emergent admittance
ADRENALINE
CRAMPS
INJECTION
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• Admitted
Preparation
– 1 mg/ml («common adrenalin»)
– 0,1 mg/ml (= 100 mikrogram/ml, ”catastrophe-adrenaline”, for newborns)
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Indication
– Astma / obstruktiv bronkitt / laryngitt
– Anafylaksi / sirkulasjonsvikt
• Dose: 10 mikrogram/kg (sc/im/iv)
INHALATION: 100 miCrogram/kg (that means 10 x the
dosis for injection)
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Preparation
– 1 mg/ml («common adrenalin»)
– rasemisk adrenalin med 10 mg/ml
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Indication
Asthma, obstructive bronkitt, laryngitt
Classic
fevercramps
– 1. x febercramps
– All other cramps
• Age 6 m - 6 y
• General (GTK)
• Duration <15
minutes
• Fever
• Before admission
– Bloodsugar?
– Temperatur/neck
stifness?
– Midazolam (buccal) or
diazepam rectal
• cramper >3-4 minutes
• May be repeated after 510 minutes: OBS
breathing
• Dosering: 100 mikrogram/kg i NaCl (til 2 ml)
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Status epilepticus
F-lab 3. floor
• Stesolid rectal 0,3-0,5 mg/kg, evt. x
2; evt Glucose i.v.
• Diazepam 0,3-0,5mg/kg iv
• Midazolam 0,15 mg/kg iv
– Evt. Epinat iv, kan gjentas
– Evt. fosfenytoin
– Evt. Fenemal iv
• Pentothal-Na (thiopental) narkose
– Evt. valproat iv
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STASJONSEKSAMEN PEDIATRI
• 13-15 minutes
• Examinator + extern
censor
• Rarely a patient
• Video, modells, blood
films or practical
question
• Sentral themes
Goals
To test
• Ability to observe
• Evaluation of history
and signs and
symptoms
• How you handle the
patient
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Lykke til med eksamen!
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