Initial Management

·    Airway

·    Breathing

·    Circulation

·    Diagnostics

·    Choking, Aspiration

·    Apnea, Poor Ventilation

·    Arrhythmia

·    Labs

·  Na, Gluc, Mg, Ca Levels

What medications do you you give patients who had a seizure?

what's first line? how do you give?

first line: ativan (benzo)

if ativan doesn't work- start at 5 min then increase over next 2-3 times (2-3 min intervals)

each time  you give at risk for apnea- so be aware

Medications

·    Antipyretic bc of fever

·    Anti-epileptic Medication

·  Diazepam, Lorazepam

·  Fosphenytoin- next step; push it via IV over 1 min- 20 mg/kg bolus; usu stops seizures; 

·  Coma induction- call anesthesia to induce coma to help with neuronal damage

·    Labs

·  Na, Gluc, Mg, Ca Levels

·    Todd’s Paralysis-unilateral decrease movement of arm and leg- usu after gen seizure- can resolve in 24 hrs

·    Epilepsy

·    Febrile Seizure

Abnormal Neuro Exam

·    Electrolytes, Glucose

·    CNS Pathology-Mass, bleed, abscess, trauma

·    Bacterial Meningitis

·    Encephalitis, Viral Meningitis

·    Shigella      

·    Todd’s Paralysis-unilateral decrease movement of arm and leg- usu after gen seizure- can resolve in 24 hrs

FALSE

·    Less than 1 yo- no Kernig’s and Brudzinki not present

·    Irritability, paradoxical consolability: want to be left alone, not touched

·    History: prodromal period

·    Vomiting due to ICP

·    Headache due to ICP

·    Fever

·    Worsening Course

·    Irritability

Etiologies:

·    E Coli, Listeria, Group B Strep

·    Pneumococcus

·    Hemophilus Influenzae

·    Meningococcus

·    **Lyme**

In the first 6 weeks of life, what organism do you worry about causing bacterial meningitis?

What is the most common cause of bacterial meningitis in older kids

What is the most treatable cause of bacterial meningitis?

First 6 weeks worry about Listeria

Most common cause of bacterial meningitis in older kids: pneumococcus

Antibioics

·    Neonatal

Cefotaxime

Ampicillin- cover for listeria

·    Older Kids

Vancomycin

·    Neurological Damage

30%

Supportive Treatments:

·    BP, ICP, AEM (anti-epileptic meds)

Typical febrile seizure:

how long do they usually last?

what age group is usually affected?

·    Typical febrile seizure

6 months- 6 years

Generalized

Short Duration

Less than 15 minutes

Majority less than 5 minutes

What can cause?

Any disease that causes fever

Rubeola can cause- HHV 6

What can cause OM? (bugs)

which do you need to treat? which can you hold off on?

S. Pneumo-need to treat

H. Infu- need to treat

M. Cat- goes away by itself

Adenovirus

Rotavirus

What's the treatment for OM?

What do you use for H. Influenza and resistent pneumococcus?

What gives you pseudomonoas coverage?

Treatment

·    First line: High Dose Amoxicillin (Macrolide)

·    Second line: Augmentin(2nd gen Cephalosporin) to catch H. Influ and resistant pneumococcus

·    3rd generation Cephalosporin Pseuodomonous coverage

·    Persistent OM/OE: suspect pseudomonas!!

Perforation (treats itself), Mastoiditis (can spread to meninges), Meningitis, Hearing impairment

·Viral- EBV CMV, Adenovirus, parainfluenza (laryngitis, stridor)

·Bacterial- Bartonella

·Post Nasal Drip

OM:

What is the drug of choice for strep throat?

What is the treatment for recurrence?

Drug of choice: penicillin

Clindamycin for recurrent

Amox for taste

·      Complications- Retro or Parapharyngeal abscess, AGN, Rheumatic Fever

If you saw this on a child: What are you thinking is the diagnosis?

 peeling of finger tips

Light sand paper rash on abdomen- may be mildly itchy

Strawberry tongue

Infants

·70% water while adults 60% due to increase body weight due to fat

·Increased insensible losses due to breathing faster, increased surface area, poor ability to concentrate urine

Lower percentage of ICF 75% to 80%

What is this describing?

·  Predominantly neurologic symptoms: Lethargy, weakness, altered mental status, irritability, seizures,  also muscle cramps, depressed deep tendon reflexes, and respiratory failure.

·  Replace free water loss slowly over 48 hours

What could cause it?

·      Hypernatremic Dehydration- GI losses, Skin Losses

What is this describing?

·  Most concerning symptom change of MS or SZ

Replace losses and treat cause over 24 hours

What could cause it?

·      Hyponatremic Dehydration- GI Losses, CF, Skin Losses, 3rd spacing

What is an early sign of tachycardia?

what are late signs?

Early sign of dehydration: tachycardia

late sign/sign of hypovolemia/hypovolemic shock: Decreased capillary refill:

Hypotension: sign of hypovolemic shock

Mental status changes: irritability, lethargy, obtunded

Pulse rate slightly increased at 5% dehydration***

Oliguria to anuria- sign of late dehydration

3-5% dehydration give oral fluids- small amounts, frequently

Worry about: rehydration- hypernatremic state to hyponatremic state can affect neuronal bodies; neuronal bodies from breaking Na down too fast

What type of event does this describe?

  “An episode that is frightening to the observer and is characterized by some combination of apnea, color change, change in muscle tone, choking, or gagging."

can be just observation

Neurological

CT scan, EEG

Pneumogram (see if central or obstructive---central could be prematurity-baby forgets to breathe)

Pulmonary

Cxray, pulse ox, RSV and Influenza

Cardiac

EKG, Echo

GI

Upper GI, PH probe

Define.

The sudden death of an infant or young child, which is unexplained by history and in which a thorough postmortem evaluation fails to demonstrate an adequate cause of death." A thorough postmortem evaluation includes a complete autopsy, review of the death scene, and review of the clinical history

how should babies be put to sleep to prevent SIDS?

What are risk factors for SIDS?

Place baby on their back

Risk Factors: Male Gender, African-American, Low BW, Prematurity, Maternal Smoking, Winter Season, Young Maternal Age, Single parenthood, multiple gestations, Higher Parity

How do you prevent SIDS?

Who gets home monitoring?

Prevention

Smoking cessation, Low BW, Prematurity, Support at Home, Co-Sleeping (sleeping in same bed as your baby)

Home Monitoring

Very Controversial

Few Actual AAP Recommendations

Who gets home monitor? Premature infants with apnea, bradycardia, and cyanosis

Monitoring of infants who are technology dependent- ie “trach kids,” or kids who require oxygen

Child Abuse

Has been increasing- almost quadrupling in numbers since 1980

___% of children in the US as diagnosed in ER

___% Physical, ___% Sexual, __% Neglect (most common- more difficult to diagnose)

____% ER concerns for abuse do not tend to be substantiated

Has been increasing- almost quadrupling in numbers since 1980

2.5% of children in the US as diagnosed in ER

30% Physical, 20% Sexual, 50% Neglect (most common- more difficult to diagnose)

55-60% ER concerns for abuse do not tend to be substantiated

Name some reasons why you might be suspicious of child abuse. (10)

·   Alcohol or substance abuse (huge risk factor for neglect)

·   Developmentally delayed Child

·   Crisis situation in the abuser’s life

·   Delay in seeking care

·   Domestic violence

·   Inappropriate affect of the caregiver

·   Mental illness or depression in the caregiver (ie. post partum depression- everyone is screened now)

·   Pattern of increased severity of injuries over time

·   History of abuse in the childhood of the abuser

·   Triggering event precipitating loss of control by caregiver

·   Unrealistic expectations of the child

General Appearance

Ht, Wt

Grooming, eye contact, parent interactions

Ophthalmological Exam

Retinal Hemorrhages from shaking baby syndrome

Skin Exam

Bruises in unexpected places, ears, perioral area

Burns- look at pattern and age of burn

CT scan

NOT an xray

·   Fractures are usually accidental

·   Multiple visits to the ER, or delay in visit

·   Some fractures are more suspicious

·   Metaphyseal bucket handle (holding leg and squeezing periosteum off bone) and corner fractures

·   Multiple, bilateral, or different stages of healing in posterior ribs and scapulae

·   Skull fractures that are multiple, complex, occipital, or posterior parietal

·   Spinous process fractures

Spiral fractures in nonambulatory infants (distal part held firmly)

What are the stats for sexual abuse in children?

% girls vs boys

·   As high as 20% in girls and 9% in males

·   Females between the ages of 8-12 most common victims

·   Poor child-parent relations, poor parent-parent relations, presence of a nonbiologically related male in house

·   Isolated child from their peers

clinging

temper tantrums

aggression

sleep disturbances

nightmares

appetite disturbances

neurotic or conduct disorders

phobias

withdrawal

depression

low self-esteem

self injury

social problems with peers

substance abuse

school problems

promiscuity

prostituition

sexual penetration on others

sexual acting out

Derm:

Lichen sclerosis

diaper dermamtitis

pinwords

poor hygiene

bubble bath

nonabusive bruising

seborrheic, atopic or contact dermatitis

lichen planus

psoriasis

bullous pemphigoid

perianal venous congestion

....there are more- refer to chart in study guide

·   Pregnancy Test

·   RPR, HIV, Hep B, Hep C, GC and Chlamydia cultures, Culture and wet mount for trich

·   Rape Kit

·   Treat for GC and Chlamydia

Consider Pregnancy Proph. And HepBIG