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  • Pedia Notes Page 1 /epcapul

    ALLERGY and IMMUNOLOGY

    IMMUNODEFICIENCY

    10 Warning signs of Immunodeficiency 8 ear infections or more within a year 2 sinus infections within a year 2 months antibiotics with little effect 2 pneumonias within 1 year failure gain weight; grow normally Recurrent abscessess Thrush in mouth or skin IV antibiotics for infections 2 deep-seated infections family history of primary immunodeficiency

    General Screening of Immunity CBC, differential, platelets IgG,IgA,IgM,IgE levels Baseline Antibody Titers

    Phagocytic Defect NBT test Rebuck skin window Chemotaxis Bacterial assay

    Complement Defect CH50 C3 C4 assay

    HIV Screening (ELISA) Positive- Probable AIDS Verify diagnosis by: repeat ELISA HIV test Western blot analysis CD4 T cell count Negative- Non-AIDS T cell defect CMI skin test (PPD, Candida antigen, etc.) CD4, CD8 assay ratio Lymphocyte blastogenic assay T cell enumeration

    ANAPHYLAXIS

    Criteria for rapid recognition of Anaphylaxis 1. Exposure to an allergen within 1 hour & 1 systemic sign 2. Urticaria or angioedema & 1 systemic sign Systemic signs: hypotension bronchospasm or dyspnea laryngeal/pharyngeal edema, stridor or dysphonia increased gastrointestinal tract motility

    Patterns Acute explosive onset within seconds to minutes of exposure to triggering event Biphasic followed by a reaction 3 to 8 hours after initial reaction (5-20% of cases) Protracted lasts 3 to 21 days from onset of acute reaction

    Laboratory findings Elevated plasma histamine Elevated serum tryptase - longer half-life

    Treatment EPINEPHRINE IS THE DRUG OF CHOICE! potent cathecholamine with both and adrenergic properties Reverses all pathophysiologic features of anaphylaxis

    -hypotension,peripheral vasodilation, increased vasopermeability, urticaria, angioedema -positive inotropic & chronotropic effects, bronchodilation, increase cAMP Epinephrine 1:1000 0.01 ml/kg SC/ IM (ped) or 0.3 to 0.5 ml (adult) given q 20 mins prn Px on blockers may be resistant to epinephrine so higher does may be required or glucagon given insect sting or injected drug: infiltrate 0.1 - 0.2 ml locally to retard absorption of the residual allergen tourniquet applied proximally if injection or sting is on an extremity

    Immediate Therapy Rapid ABCs of resuscitation Epinephrine IV (1:100,000) = 0.01 mg/kg or continuous drip 0.1-0.2 g/kg/min titrated q 0.1 g/kg/min to max of 1.5 g/kg/min Separate IV line no HCO3 infusion Continuous monitoring of CVS status and O2 Rapid HX of triggering event, current medications, HX of asthma, allergies and concomitant medical conditions Subacute H1 blocker Diphenhydramine 1-2 mg/kg PO,IM,IV Chlorpheniramine 10-20 mg IV,IM Corticosteroids Hydrocortisone 4-8 mg/kg/dose or methylprednisolone 1-2 mg/kg Iv q 6 h 2 agonist nebulization q 20 mins of continuous Secondary H2 blocker Ranitidine IV or PO 2-4 mg/kg/day q 8 h Glucagon 0.1 mg/kg IV if refractory to initial TX Observe at least 4 hours for biphasic anaphylaxis Fluids Loss of up to 50% intravascular volume may occur resulting in profound hypotension not responsive to epinephrine Antihistamines are not appropriate monotherapy for the Tx of acute anaphylaxis Corticosteroids are used to prevent the biphasic response and to control bronchospasm Bronchodilators are useful adjuncts in TX esp in those with asthma

    CARDIOLOGY

    Heart Rate Age Awake Mean Sleeping NB-3mos 85-205 140 80-160 3mos-2yrs 100-190 130 75-160 2-10yrs 60-140 80 60-90 >10yrs 60-100 75 50-90 Prob SVT (nQRS) >220 infants, >180children

    Cardioversion/ Defibrillation: 0.5-1J/kg (VT); 2-4J/kg (VF/ Pulseless VT)

    ECG

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    Normal Axis Newborn 0- (+)180 1- 6 m0 (+)10- (+)125 6mo- 3yr (+)10- (+)110 >3yr 0- (+)90

    PR 0.12-0.20sec QRS 0.08-0.12sec ST not >1mm in limb leads; not >2mm in precordial QTc 0.44sec 3-4days; 0.45 25 qR in V1 upright T in V1 >3day R in avR8mm RVH in Children RV1 >20, SV6 >7 qR in chest leads upright T >3yo RV110mm T wave inversion in avF R/S ratio in V1 >1 RsR in V1 RAD >3mos

    LVH SV1 >20, RV6 >25 Asymmetric T wave inversion inV5 & V6 SV1 + RV6 >50mm Qwave >30mm in II, III, aVF, V5-6

    CVH Direct signs of RVH & LVH LVH + RAD & tall R in V1 RVH + q 2 mm in V5 & V6, tall R in V6, & inverted T in V6 Large equiphasic QRS in V2- V4, R + S >60 mm- Katz-Wachtel phenomenon

    QTc (corrected QT) - Bazetts Formula: ____QTa______ RR interval where RR interval = # of small squares between R-R x 0.04 sec First Degree AV Block There must be P waves There must be one P wave to each QRS complex P waves have morphology and axis usual for the subject QRS complex must have morphology and axis usual for the subject P-R interval is constant P-R interval is prolonged (i.e. >0.20 sec.)

    Second degree AV block Mobitz type 1- Wenkebach phenomenon there must be P waves there must be QRS complexes P waves must have morphology and axis usual for the subject Progressive prolongation of P-R interval with each succeeding beat

    until there is a dropped beat

    Second degree AV block Mobitz type 2 there must be P waves & QRS complexes P waves have morphology and axis usual for the subject QRS complex must have morphology axis usual for the subject P-R interval of conducted beats may be normal or long but fixed, then

    there is a dropped beat

    High Grade AV Block Some P waves are followed by QRS complexes and some are not Atrio-ventricular conduction ratio is 3:1 or higher P-R interval of beats in which a QRS complex follows a P wave may

    be normal or long but must be constant

    Third degree AV block Any form of atrial activity may be seen or there may be no atrial

    activity no consistent or meaningful relationship between atrial and ventricular

    activity. Variable PR and RP intervals. QRS may be normal in shape, duration and axis but more often are

    abnormal and are of constant morphology QRS rate is usually constant and lies within the range of 15-70

    beats/min.

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    CHEST XRAY ABNORMAL PATTERN RAE AP: >1/3 of the right RVE

    AP: apex upturned / rounded Lateral: obliteration of the retrosternal space; filled only normally.

    Displacement of LV posteriorly. Behind shadow of IVC LAE

    AP: increased distance between the right wall of the left atrium and left main stem bronchus (double density); 3.5cm for infants, 4.5cm for children; Prominence of left atrial appendage or so called disappearance of cardiac waistline; elevation of left main stem bronchus.

    Lateral: elevation of left main stem bronchus; discrete bulge in the region of the left atrium which pushes the esophagus posteriorly

    LVE AP: prominent left heart border and mid-left heart concavity with apex displaced posteriorly and meets IVC at the diaphragm level

    MYOCARIDAL INFARCTION IN CHILDREN ECG Findings New onset wide Q waves (>0.035 sec) seen within first few hours and

    persistent over several years ST-segment elevation (>2mm) seen within the first few hours Diphasic T waves seen within first few days (beginning sharply

    inverted) then normalizing over time Prolonged QT interval (>0.44 sec) with accompanying abnormal Q

    waves Deep wide Q waves in Leads I, avL, or V6 contrast Q waves in II, III,

    avF Other criteria Elevated creatinine kinase / MB although this is not specific for

    detection of acute MI in children Cardiac Troponin I is a more sensitive indicator of early myocardial

    damage in children elevated within hours of cardiac injury, persists for 4-7 days, specific for cardiac injury

    CARDIOVASCULAR MEDICATIONS Inotropes: agents that improve myocardial contractility and enhance

    stroke volume Pressors: agents that increase systemic vascular resistance and

    increase blood pressure Chronotropic: Increase heart rate Lusotropic: improve relaxation during diastole and decrease EDP in

    the ventricles ALPHA-ADRENERGIC MEDICATIONS Alpha1-adrenergic effects: Vascular smooth muscle contraction Alpha2-adrenergic effects: Vascular smooth muscle relaxation--this is

    a very mild effect only at low doses of an alpha-adrenergic agent like epinephrine.

    BETA-ADRENERGIC MEDICATIONS Beta1-adrenergic effects:Direct cardiac effects: (a) Inotropy (improved

    cardiac contractility) (b) Chronotropy (increased heart rate) Beta2-adrenergic effects: (a) Vasodilation (b) Bronchodilation

    CARDIAC MEDS VIA CONTINUOUS INFUSION EPINEPHRINE Both an alpha- and beta-adrenergic agent Indications for its use as a continuous infusion are: o low cardiac output state beta effects will improve cardiac function alpha effects may increase afterload and decrease cardiac output septic shock - useful for both inotropy and vasoconstriction

    Actions are dose dependent (mcg/kg/min): o 0.02-0.08 = mostly beta1 and beta2 stimulation. increased cardiac output mild vasodilation o 0.1-2.0 = mix of beta1 and alpha1 increase cardiac output increase SVR = vasoconstriction o > 2.0 = mostly alpha1 increase SVR, and may decrease CO by increasing afterload

    Side effects include: Anxiety, tremors,palpitations

    Tachycardia and tachyarrhythmias Increased myocardial oxygen requirements and potential to cause

    ischemia Decreased splanchnic and hepatic circulation (elevation of AST and

    ALT) Anti-Insulin effects: lactic acidosis, hyperglycemia

    NOREPINEPHRINE Employed primarily for its alpha agonist effect - increases SVR (and

    B.P.) without significantly increasing C.O. Used in cases of low SVR and hypotension such as profound warm

    shock with a normal or high C.O. state Infusion rates titrated between 0.05 to 1 mcg/kg/min In general, norepinephrine differs from epinephrine in that at doses

    used in clinical practice, the vasoconstriction outweighs any increase in cardiac output.

    o i.e. norepinephrine usually increases blood pressure and SVR, often without increasing cardiac output.

    Side Effects: Similar to those of Epinephrine Can compromise perfusion in extremities and may need to be

    combined with a vasodilator e.g. Dobutamine or Nipride More profound effect on sphlancnic circulation and myocardial

    oxygen consumption DOPAMINE Intermediate product in the enzymatic pathway leading to the

    production of norepinephrine; thus, it indirectly acts by releasing norepinephrine.

    Directly has alpha, beta and dopaminergic actions which are dose-dependent.

    Indications are based on the adrenergic actions desired. Improve renal perfusion 2-5 mcg/kg/min Improve C.O. in mild to moderate Cardiogenic or Distributive Shock 5-

    10mcg/kg/min Post-resuscitation stabilization in patients with hypotension (in

    conjuction with fluid therapy) 10-20mcg/kg/min DOBUTAMINE Synthetic catecholamine with inotropic effect (increases stroke

    volume) and peripheral vasodilation (decreases afterload) Positive chronotropic effect (increases HR) Some lusotropic effect Overall, improves Cardiac Output by above beta-agonist acitivity o Major metabolite is 3-O-methyldobutamine, a potent inhibitor of alpha-

    adrenoceptors.Therefore, vasodilation is possible secondary to this metabolite.

    Usual starting infusion rate is: 5 mcg/kg/min, with the dose being titrated to effect up to 20 mcg/kg/min.

    Used in low C.O. states and CHF e.g. myocarditis, cardiomyopathy, myocardial infarction

    If BP adequate, can be combined with afterload reducer (Nipride or ACE inhibitor)

    In combination with Epi/Norepi in profound shock states to improve Cardiac Output and provide some peripheral vasodilatation

    MILRINONE/AMRINONE Belong to new class of agents Bipyridines Non-receptor mediated activity based on selective inhibition of

    Phosphodiesterase Type III enzyme resulting in cAMP accumulation in myocardium

    cAMP increases force of contraction and rate and extent of relaxation of myocardium

    Inotropic, vasodilator and lusotropic effect AMRINONE

    First generation agent - limited use now Long half-life (4.4 hours) with potential for prolonged hypotension

    after loading dose Associated with thrombocytopenia Dosage: Load with 0.75 mg/kg with infusion rate of 5-10 mcg/kg/min Milrinone is preferred drug from this group

    MILRINONE Increases CO by improving contractility, decreased SVR, PVR (?),

    lusotropic effect; decreased preload due to vasodilatation Unique in beneficial effects on RV function Half-life is 1-2 hours

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    Load with 50 mcg/kg over 30 mins followed by 0.3 to 0.75 mcg/kg/min

    No increase in myocardial O2 requirement VASODILATORS

    Classified by site of action Venodilators: reduce preload - Nitroglycerin Arteriolar dilators: reduce afterload Minoxidil and Hydralazine Combined: act on both arterial and venous beds and reduce both

    pre- and afterload Sodium Nitroprusside (Nipride) NITROPRUSSIDE

    Vasodilator that acts directly on arterial and venous vascular smooth muscle.

    Indicated in hypertension and low cardiac output states with increased SVR.

    Also used in post-operative cardiac surgery to decrease afterload on an injured heart.

    Action is immediate; half-life is short; titratable action. Toxicity is with cyanide, one of the metabolites of the breakdown of

    nipride. Severe, unexplained metabolic acidosis might suggest cyanide

    toxicity. Dose starts at 0.5 mcg/kg/min and titrate to 5 mcg/kg/min to desired

    effect. May go higher (up to 10 mcg/kg/min) for short periods of time.

    NITROGLYCERIN Direct vasodilator as well, but the major effect is as a venodilator

    with lesser effect on arterioles. Not as effective as nitroprusside in lowering blood pressure. Another potential benefit is relaxation of the coronary arteries, thus

    improving myocardial regional blood flow and myocardial oxygen demand.

    Used to improve myocardial perfusion following cardiac surgery Dose ranges from 0.5 to 8 mcg/kg/min. Typical dose is 2

    mcg/kg/min for 24 to 48 hours post-operatively Methemoglobinemia is potential side effect

    ISOPROTERENOL Synthetic catecholamine Non-specific beta agonist with minimal alpha-adrenergic effects. Causes inotropy, chronotropy, and systemic and pulmonary

    vasodilatation. Indications: bradycardia, decreased cardiac output, bronchospasm

    (bronchodilator). No longer available in some markets Occasionally used to maintain heart rate following heart

    transplantation. Dose starts at 0.01 mcg/kg/min and is increased to 1.0 mcg/kg/min

    for desired effect. INHALED NITRIC OXIDE

    Selective Pulmonary vasodilator Dilates only pulmonary capillaries to alveoli participating in gas

    exchange Decreases intrapulmonary shunt and improves V/Q matching Rapidly inactivated by Hgb in pulm. cap. so no systemic side effects

    (eg hypotension) Potential for use in ARDS and Pulmonary Hypertension Currently only approved for use in neonatal Pulmonary

    Hypertension Expensive Special monitoring equipment required Dose: Concentration of 0.5-60 ppm in inhaled gas

    CARDIAC ARREST MEDICATIONS EPINEPHRINE Both an alpha- and beta-adrenergic agent During an cardiac arrest, most think it has the greatest benefit by

    alpha-adrenergic actions, increasing afterload and thus diastolic blood pressure, leading to improved coronary artery perfusion.

    Indications: o Cardiac arrest o Severe bronchospasm o Anaphylactic reactions

    Route of Administration

    o IV or IO o SQ or IM (for bronchospasm) o ET (cardiac arrest without IV or IO access)

    Dosage: o initial (low) dose: 0.01 mg/kg o = 0.1 cc/kg of 1:10,000 o subsequent (high) doses: 0.1 mg/kg o = (0.1 cc/kg of 1:1,000)

    ATROPINE Parasympathetic (not an alpha- or beta-adrenergic) agent--acts by

    blocking cholinergic stimulation of the muscarinic receptors of the heart.

    Results in an increase in the sinus rate of the heart. Little effect on systemic vascular resistance or myocardial contractility. Indications: o Bradycardia o Second or third degree heart block o Asystole o Pulseless electrical activity (electrical mechanical dissociation)

    o Route of Administration: IV, IO, ET, SQ, IM, nebulization Dosage: o 10 to 20 mcg/kg o minimum dose is 0.1 mg--smaller doses may cause reflex

    bradycardia (central stimulatory effect on the medullary vagal nuclei)

    o maximum (adult) dose is 2 mg SODIUM BICARBONATE Use during CPR remains a controversial issue due to lack of evidence

    showing benefit from receiving bicarbonate. Elevates blood pH by binding with hydrogen to form water and CO2 HCO-3 + H+ => H2CO3 => H2O + CO2 Must have adequate ventilation to remove CO2 or respiratory acidosis

    will worsen Adverse effects of acidosis: o Cardiac Decrease contractility Lower threshold for ventricular fibrillation Decrease responsiveness to catecholamines o Vascular Decrease systemic vascular resistance Decrease systemic vascular responsiveness to catecholamines Increase pulmonary vascular resistance

    Indications: o Pre-existing acidosis o Prolonged CPR (after 10 minutes) o Pulmonary hypertensive crisis o Hyperkalemia

    Route of administration: IV, IO o Dosage: 1-2 meq/kg/dose (1 meq/cc or 0.5 meq/cc) CALCIUM Current recommendations for the use of calcium during CPR are

    restricted to a few specific situations. Intracellular calcium plays an important role in the process of cell

    death, but no studies have shown that transient hypercalcemia worsens outcome after cardiac arrest.

    Adverse Effects of Hypocalcemia o Decreased myocardial contractility o Decreased systemic vascular resistance o Decreased catecholamine release o Decreased cardiovascular response to catecholamines

    Indications: o Hypocalcemia Ionized hypocalcemia may result from severe alkalosis or after large

    transfusions of citrated blood products. o Hyperkalemia o Hypermagnesemia o Calcium channel blocker overdose

    Route of administration: o IV, IO only o Calcium chloride--central venous line o Calcium gluconate--peripheral venous line

    Dosage: o Calcium chloride = 10-20 mg/kg o Calcium gluconate = 100-200 mg/kg

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    LIDOCAINE Class 1B antiarrhythmic Decreases automaticity threshold and ventricular fibrillation threshold. Effective in terminating PVCs. Rarely used in pediatric arrests as ventricular tachycardia and

    ventricular fibrillation are not commonplace. Indications: o Ventricular Tachycardia o Ventricular Fibrillation o Frequent PVCs

    Route of Administration: IV, IO, ET o Dosage: 1 mg/kg/dose (may need up to 2.5 mg/kg ET)

    ENDOTRACHEAL MEDICATIONS (LEAN) o Lidocaine o Epinephrine o Atropine o Naloxone (Narcan)

    RHEUMATIC FEVER

    Guidelines for the Diagnosis of Initial Attack of Rheumatic Fever (Jones Criteria, Updated 1992)

    MAJOR MANIFESTATIONS

    MINOR MANIFESTATIONS

    SUPPORTING EVIDENCE OF ANTECEDENT GROUP A STREPTOCOCCAL INFECTION

    Carditis Clinical features: Positive throat culture or rapid streptococcal antigen test

    Polyarthritis Arthralgia Fever Elevated or increasing

    streptococcal antibody titer

    Erythema marginatum Laboratory features: Subcutaneous nodules

    Elevated acute phase reactants:

    Erythrocyte sedimentation rate

    C-reactive protein Prolonged PR interval Chorea intended only for the diagnosis of the initial attack of acute rheumatic

    fever and not for recurrences 5 major and 4 minor criteria and an absolute requirement for evidence

    (microbiologic or serologic) of recent GAS infection. Diagnosis of acute rheumatic fever: 2 major criteria or 1 major and 2

    minor criteria and meets the absolute requirement. Chorea may occur as the only manifestation of acute rheumatic fever. Indolent carditis may be the only manifestation in patients who 1st

    come to medical attention months after the onset of acute rheumatic fever

    Criteria for determining activity: joint symptoms new significant murmur increasing heart size congestive heart failure in the absence of old valvular disease subcutaneous nodules rectal temperature >100.4 F for at least 3 consecutive days sleeping pulse of >100/min positive C-reactive protein *considered active if any one of the following findings is present

    RHEUMATIC HEART DISEASE MR/MS is appreciated on PE LVH/RVH on ECG irregular cardiac borders on CXR *In RF there is also cardiomegaly but with normal ECG findings

    INFECTIVE ENDOCARDITIS (Duke criteria) Major criteria (1) positive blood cultures (two separate cultures for a usual pathogen, two or more for less typical pathogens) and (2) evidence of endocarditis on echocardiography (intracardiac mass on a valve or other site, regurgitant flow near a prosthesis, abscess, partial dehiscence of prosthetic valves, or new valve regurgitant flow) Minor criteria (1) predisposing conditions (2) fever (3) embolic-vascular signs (4) immune complex phenomena (glomerulonephritis, arthritis, rheumatoid factor, Osler nodes, Roth spots) (5) a single positive blood culture or serologic evidence of infection (6) echocardiographic signs not meeting the major criteria. Definite Endocarditis: Two major criteria, one major and three minor, or five minor criteria

    KAWASAKI DISEASE Clinical and Laboratory Features EPIDEMIOLOGIC CASE DEFINITION (CLASSIC CLINICAL CRITERIA) Fever persisting at least 5 days Presence of at least 4 principal features: Changes in extremities

    Acute: Erythema of palms, soles; edema of hands, feet Subacute: Periungual peeling of fingers, toes in weeks 2 and 3

    Polymorphous exanthema Bilateral bulbar conjunctival injection without exudates Changes in lips and oral cavity: Erythema, lips cracking, strawberry

    tongue, diffuse injection of oral and pharyngeal mucosae Cervical lymphadenopathy (>1.5 cm diameter), usually unilateral Exclusion of other diseases with similar findings

    3 Clinical phases: Acute Febrile Phase ( 1-2 weeks ) fever, conjuctivitis, erythema, rash Subacute Phase ( 2-4 weeks ) begins when the fever stops desquamation, thrombocytosis, coronary aneurysms Convalescent Phase ( 4-6 Weeks ) resolution of all sign & symptoms labs return to normal coronary aneurysms persists

    Coronary Aneurysms Classification of CAA Small - 8 mm internal diameter

    Treatment Acute Stage Intravenous Immunoglobulin: 2g/kg over 10-12 hours With Aspirin (80-100 mkd) q6, until day 14 of illness and afebrile for 48 to 72 hrs This therapy should be instituted within the 1st 10 days of illness and if possible within 7 days of illness. Convalescent Stage Aspirin (3-5 mkd) OD, until the patient shows no evidence of CA changes by 6-8 weeks after the onset of illness. IVIG also should be administered to children presenting after the 10th day of illness Long Term: Coronary Abnormalities Aspirin (3-5 mkd) divided dosed, continued indefinitely High dose intravenous gammaglobulin (IVIG) effective in preventing the occurrence of coronary artery

    abnormalities in KD. Patients treated with IVGG have a significant increase in T suppressor

    cells, a decrease in circulating activated T helper cells, and a decrease in spontaneous IgG and IgM synthesis.

    suggest that IVGG reduces the vasculitis in KD by suppressing the marked immune activation associated with this disease.

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    Measles and Varicella immunization should be deferred for 11 months after child receives high-dose of IVIG

    Even when treated with high-dose of IVIG within the 1st 10 days of illness, 5% of children develop at the least transient coronary artery dilation and 1% develop giant aneurysms.

    Careful monitoring is necessary during the administration of gamma globulin because it rarely can cause an allergic-like reaction.

    DEVELOPMENT

    Anterior fontanelles closed at 7-19 months Posterior fontanelle closed at 3 months

    ANTHROPOMETRICS Length/Height Average Birth Length: 50cm Length: 9-8-5-3cm Height: agex5+80

    Weight Average BW: 3000 1-6mos= age in mos x 600 + BW 7-12mos= age in mos x 500 + BW 1-6yrs=agex2+8 7-12yrs=agex7-5/2

    BSA: square root of (wt x ht / 3600)

    Head Circumference Average 13-14in 0-4 mos 2in 5-12mos 2in 1-2 yrs 2 in 2-5 yrs 2 in 5-20 yrs 2 in

    OR Average: 35cm 0-3mos 2cm/mo 3-6 1cm/mo 6-9 0.5cm/mo 9-12 0.5cm/mo 1-3yrs 0.25cm/mo 4-6yrs 1cm/yr

    Height age age points on the growth curve where the childs height falls on the 50th percentile Weight age age point on the weight curve where the childs weight falls on the 50th percentile

    Midparental height 7 (for girls) 10 Midparental height + 7 (for boys) 10 OR For Males: (mothers height + 13cm + fathers height) 5 2 For Females: (Fathers height - 13cm + mothers height) 5 2 Growth Velocity (cm/yr) Ht (cm) measured at Time 2 - Ht (cm) measured at Time 1 X 12 (mos/yr) Number of months between time 2 and time 1

    Age Rate (cm/yr) 1-2 month 38 4 months 28

    1 year 12 2 years 10

    3-4 years 7 5-6 years 6 7-puberty 5

    Arm Span Age Arm Span

    Boys: 95th percentile

    Body proportions Upper segment sitting height (measure using Harpenden sitting table) Lower segment measure from upper border of symphysis pubis to floor in standing position US/LS: Birth = 1,7; 10 years 1

    Sexual Maturity Rating Girls Stage Breast Pubic Hair 1 Preadolescent Preadolescent 2 Breast and papilla elevated as

    small mound, diameter of areola is increased

    Sparse, lightly pigmented, straight, medial border of labia

    3 Breast and areola enlarged, no contour separation

    Darker, beginning to curl, increased amount

    4 Areola and papilla form secondary mound

    Coarse, curly, abundant but less than in adult

    5 Mature nipple projects, areola part of general breast contour

    Adult feminine triangle, spread to medial surface of thighs

    Boys Stage Penis Testes Pubic Hair

    1 Preadolescent Preadolescent None 2 Minimal change

    / Enlargement Enlarged scrotum, pink texture altered

    Scanty, long, slightly pigmented

    3 Lengthens Larger Darker, beginning to curl, small amount

    4 Larger; Glans and breadth increase in size

    Larger, scrotum dark

    Resembles adult type, but less quantity; coarse, curly

    5 Adult size Adult size Adult distribution, spread to medial surface of thighs

    RED FLAGS Motor Delay poor head control by 3 months hands still fisted by 4 months unable to hold objects by 7 months does not sit independently by 10 months cannot stand on one leg by 3 years Language Delay does not turn to sound by 6 months does not babble or use gestures by 12 months no single word utterances by 16 months No 2-word phrases by 2 years No 3-word sentences by 3 years Psychosocial Delay No social smile by 3 months Not laughing in playful situation by 6 months Hard to console, stiffens when approached by 1 year In constant motion, resists discipline Does not play with other children at 3 years Cognitive delay - 2 months Not alert to mother -6 months Not searching for dropped objects - 12 months No object permanence - 18 months No interest in cause-and-effect games - 2 years Does not categorize similarities - 3 years Does not know full name -4 years Cannot count sequentially - 5 years Does not know letters or colors -5 years Does not know birthday or address

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    ENDOCRINOLOGY

    IDF definition of Metabolic Syndrome in children and adolescents Age 6 to 200 mg/dl (11.1 mmol/l) heavy glycosuria (>55 mmol/l) ketonuria acidosis (pH < 7.3) ( HCO3 < 15 mmol/l) 5% or more dehydrated vomiting / drowsy

    Principle 1:Restoration of vascular volume In shock with poor peripheral perfusion or coma: give 10 cc/kg x 10-30 min Repeat if poor pulses remain Fluid of choice: 0.9 NSS Fluid input > 4li/m2 : incrd risk for cerebral edema

    IV therapy MODEL 1 Reqts = Deficit + Maintenance Maintenance: 3 9 kg 80 cc/kg/d 10-19 kg 70 cc/kg/d 20-30 kg 60 cc/kg/d 30-50 kg 50 cc/kg/d >50kg 35 cc/kg/d Add deficit to 48 hr MTN; Replace for 48 hrs w/ PNSS

    MODEL 2 Covers maintenance + 10% deficit, give evenly for 48 hrs. 3 9 kg 6 cc/kg/hr

    10 19 kg 5 cc/kg/hr 20 kg 4 cc/kg/hr (max 250 cc/hr)

    Compute for the fluid requirement of VJ ( BW=35 kg) Deficit: 35 x 60cc= 2100 ml (assume mod dehydration unless shocky) Maintenance: (35 x 50) x 2=35000 Total fluid for 48h: 5600 ml

    Monitor urine output especially during the first 4-6 hours of therapy Replace urine losses volume per volume Entails frequent changing rate of infusion Potassium supplementation Start as early as the 3rd hour or even earlier as long as the patient is voiding Shift to a glucose containing solution when the blood glucose is down to 200 mgs%

    Principle 2:Inhibition of lipolysis and correction of hyperglycemia Insulin therapy Only short-acting insulin is used ( Humulin R, Actrapid ) Should not be started until shock has been reversed IV route only Target fall in blood glucose: 50-100 mg per hour

    Low dose continuous Insulin Infusion 0.1 u/kg/hr (consider 0.05 u/kg/hr for a young child)

    Hourly blood glucose, fluid input and output Neurological status at least hourly Electrolyte 2 hrs after start of IV therapy Monitor ECG for T wave changes

    How to prepare insulin infusion? Mix 10 U SA insulin in 100 cc plain NSS 0.1 u/ml Flush tubings with solution

    For VJ: 35 kg x .1u/kg/hr= 3.5 u 35 ml/hr So, always prepare a solution as above so that infusion rate is equal to the weight of the patient

    When do you stop insulin infusion? acidosis is resolved patient is awake

    How to shift to subcutaneous route? Compute at .15-.25 u/kg/dose q6h to be given 30 min pre-meals and

    at MN D/C infusion 30 min after 1st SQ dose

    Principle 3:Correction of acidosis Sodium Bicarbonate therapy pH < 7.0 HCO3 < 5meq/li Half-correction over 30 minutes - 1 hour

    THYROID STORM Precipitating factors for thyroid storm Infection Surgery (thyroidal and nonthyroidal) Therapy with radioactive iodine Administration of iodinated contrast dyes or ingestion of large, stable iodine loads Withdrawal of antithyroid medication Amiodarone therapy Ingestion of excessive amounts of exogenous thyroid hormone Diabetic ketoacidosis Congestive cardiac failure Hypoglycemia Toxemia of pregnancy Parturition and the immediate postpartum state Severe emotional stress Acute manic crisis

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    Pulmonary embolism Cerebral vascular accident Bowel infarction Acute trauma Tooth extraction Vigorous palpation of thyroid gland

    The predictive clinical scale for thyroid storm (Burch and Wartofsky) Parameter taken into consideration

    Scoring points

    Thermoregulatory dysfunction, Temperature (oral) 99-99.9F 37.2-37.7C 5 100-100.9F 37.8-38.2C 10 101-101.9F 38.3-38.8C 15 102-102.9F 38.939.3C 20 103-103.9F 39.4-39.9C 25 >104F >40C 30 CNS effects Absent 0 Mild (agitation) 10 Moderate (delirium, psychosis, extreme lethargy)

    20

    Severe (seizures, coma) 30 GI-hepatic dysfunction Absent 0 Moderate (diarrhea, nausea/vomiting, abdominal pain)

    10

    Severe (unexplained jaundice) 20 Tachycardia (beats/min) 99-109 5 110-119 10 120-129 15 130-139 20 >40 25 Congestive cardiac failure Absent 0 Mild (pedal edema) 5 Moderate (bibasal rales) 10 Severe (pulmonary edema) 15 Atrial fibrillation Absent 0 Present 10 Precipitating event Absent 0 Present 10 A cumulative score of >45 is highly suggestive of thyroid storm, 25-44 is suggestive of impeding storm, and 10 kg > 20 kg 1500 ml + 20 ml/kg for each kg > 20 kg

    Body Surface Method Requirements Water 1500 ml/m2/day Na+ 30-50 meq/m2/day K+ 20-40 meq/m2/day

    Factors Modifying Fluid Requirements Additional Fluids Needed fever 12% for each C > 37.5C sustained hyperventilation or excessive muscular activity

    25-50%

    hypermetabolic states 25-75% for burns: 2% increase per 1% BSA with burns

    diarrhea and vomiting volume per volume sweating 10-25% room temperature > 31C 30% per C rise > 31C newborn under radiant warmer or phototherapy

    25%

    Less Fluids needed hypothermia 12% per C fall below 37.5C very high humidity 30% humidified inspired air 25% oliguria or anuria Individualized sedated or paralyzed 40%

    Electrolyte Daily Requirement (meq/kg/day) Na+ 2.5-3.0 K+ 2.0-2.5

    Determine the fluid deficit Severity of Dehydration Infant Child (>10 kg) mild 50 cc/kg 30 cc/kg moderate 100 cc/kg 60 cc/kg severe 150 cc/kg 90 cc/kg determine the maintenance fluid requirement give the of the fluid deficit over the 1st 8 hours then over the next 16 hours re-assess hydration status periodically for moderate to severe dehydration, check serum electrolytes

    ELECTROLYTES Na 135-145; K 3.5-5; Ca 2.1-2.6; HCO3 22-26

  • Pedia Notes Page 9 /epcapul

    IVF IVF Na+

    (meq/L) K+ (meq/L)

    Cl- (meq/L)

    HCO3- (meq/L)

    Mg++ (mg/dL)

    Ca++ (mg/dL)

    pLR 130 4 109 28 (lactate)

    - 3

    pNSS 154 - 154 - - - D5 0.3NaCl

    51 - 51 - - -

    D5IMB 25 20 22 - 3 - D5NR 140 5 98 27

    (acetate) - -

    D5NM 40 13 40 16 (acetate)

    3 -

    HYPONATREMIA Fast correction: -4mL/kg/dose of 3% NaCl -3% NaCl= 1mL (2meqs/mL NaCl + 4mL sterile water) -Total Na required= (M+D) bolus M= 3meqs/kg/day D= (desired Na actual Na) x o.6 x wt

    HYPERNATREMIA Total water required for 2 days = (M for 2 days +D) bolus Ideal TBW (in liters)= wtx 0.6; ideal serum Na 140 Water deficit= ideal TBW actual TBW Actual TBW= ideal TBW x ideal serum Na/actual serum Na

    CORRECTED SODIUM Glucose in mg/dL Na+ + Glucose -100 x 1.6 100 Glucose in mmol/L Na+ + Glucose -5.6 x 1.6 5.6

    HYPOKALEMIA Fast correction 0.5meqs/kg/dose in PNSS diluent x 1hour x 3-5 doses (max 40meqs/L) Example: Wt 20kg: (0.5meg/kg/dose K? x 20kg =10meq/hr

    Compute how much diluent is required. Central line (200meq/L concentration) 200meq = 10meq 1000mL x X=50mL Order: Give 10meq K in 50mL NSS x 1hr Peripheral line (60meq/L concebtration) 60meq = 10meq 1000mL x X=170mL Order: Give 10meq K in 170mL NSS x 1hr

    Bedside Pediatric Nephrology PO correction is potassium chloride of 4-6meg/kg/day given in divided doses. Parenteral correction Intermittent Dosing: (for symptomatic hypokalemia) 0.5 to 1.0meq/kg/hr (maximum 30meq/hr) with maximum infusion rate of 0.5meg/kg/hr and given Q2-4hours until symptoms resolve. Continuous Dosing: (for non-symptomatic hypokalemia) 0.2-0.3meg/kg/hr for 24hours *always consider the possibility of Magnesium deficiency especially among patients with refractory hypokalemia. Magnesium is a important co-factor for the activity of the Na-K-ATPase pump which is necessary for potassium homeostasis.

    Hariett Lane: Oral: Child: 1-4meg/kg/24hrBID-QID Adult: 40-100meq/24hrBID-QID

    IV: Child: 0.5-1meq/kg/dose given as an infusion of 0.5meq/kg/hr x 1-2hr Max: 1meq/kg/hr. This may be used in critical situations(i.e. hypokalemia with arrhythmia) Adult: Serum K >2.5meq/L: Replete at rates up to 10meq/hr. Total dosage not to exceed 200meq/24hr Serum K

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    factor = desired dextrosity lower dextrosity higher dextrosity lower dextrosity amount of D50 to be added to actual IVF = (factor)(actual IVF being given) peripheral line D12 central line D20 Glucose Infusion Rate determines adequacy of infused glucose (dextrosity)(drip rate in cc/hr)(0.167) body weight (kg) nv: infants 6-8; children 4-6 GIR normal = 5-8 GIR = rate (gtts/min) x dextrosity x 1,000 Weight x 60

    BURN Parkland D1: 4ml/ k/ %BSA burned x hrs, x 16hrs + maintenance D2: 50-75% of above Maintenance fluids should be estimated for children who weigh 40kg, maintenance fluids are not

    included in the estimate of fluid requirements Half of this volume is given in the first 8 hours after injury and the other

    half is given in the following 16 hours

    GASTROENTEROLOGY

    NUTRITIONAL STATUS ASSESSMENT WATERLOWE CLASSIFICATION S: 90-95 (Mi); 80-90 (Mod); 2yrs serious reflux esophagitis 1 mkd for 4-8 wks > 20 kg 20 mg OD 10-20kg 10 mg OD - NSAID induced gastric and duodenal ulcer : 20 mg OD x 4-8 wks - GERD 10-20 mg OD x 2-4 wks - symptomatic GERD w/ esophageal lesions 20 mg OD x 4 wks -maintenance of healing of erosive esophagitis 20 mg OD up to 12 mos Eradication of H. pylori BID x 1 wk: Omeprazole 20 mg + Amox 1000 mg + clarithromycin 500 mg BID x 1 wk: Omeprazole 20 mg + Metro 500 mg + clarithromycin 250 mg

    CALORIC COMPUTATION Protein: gm/k/d x wt x 4; requirement 0.5-3gm/k/d Lipid: gm/k/d x wt x 9; requirement 0.5-4gm/k/d CHO: gm/100cc x vol x 4 (eg. D5=5gm/100cc) CALORIC DISTRIBUTION OF CHO, COOH, CHON OF TOTAL CALORIES GIVEN CHO 60-70% CHON 10-15% Fats 20-30% Breastmilk: 20cal/oz; VCO: 7.7cal/cc; Cereal 12.4cal/scoop 1gm Nitrogen = 6.25gm protein Supplements for Severe Malnutrition: 50% MgSO4 2ml (2mmol/mL) IM x 1 dose; Zn 1mkd until diarrhea stops; Cu 0.1mkd; Folic acid 5mcg/k/d; Fe 3mkd; Vit A (if not given w/in 6mos) 1yr 200,000iu Age REE Multiplication factor 0-1 55 Maintenance 0.2 1-3 57 Acitivity 0.1-0.25 4-6 48 Fever 0.13/deg >38C 7-10 40 Simple Trauma 0.2 11-14 32M/ 28F Multiple Injuries 0.4 15-18 27M/ 25F Burns/ GI surgery 0.5-1 Total Daily Energy Req: REE + REE x Total factors

    Sepsis 0.4 Growth 0.5

    FORMULA FOR CALORIC REQUIREMENT FOR CATCH-UP GROWTH Get the height, weight get ideal weight for actual height kcal/kg=RDA for age (kcal/kg) x ideal wt/ht actual wt CHON=CHON recommended for age x ideal wt/ht Actual wt * start by 50-70% of caloric requirement * increase calories by 20 kcal/kg/k every 2 days until caloric requirement is reached * increase protein by 0.5 g/kg every 2 days until catch up is reached RDA for CHON (g/kg/day) 0-6 mos 2.2 7-12 mos 1.5 1-2 yrs 1.1 3-8 yrs 0.95 9-13 yrs 0.95 14-18 yrs 0.85

    RECOMMENDED ENERGY INTAKE (kcal/kg) per kg per day Infants 0-6mos 108 650

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    6-12 mo 98 852 Children 1-3 yr 102 1,300 4-6 yr 90 1,800 7-10 yr 70 2,000 Males 11-14 yr 55 2,500 15-18 45 3,000 19-24 40 2,900 25-50 30 2,900 > 50 30 2,300 Females 11-14 yr 47 2,200 15-18 40 2,200 19-24 38 2,200 25-50 36 2,200 > 50 30 1,900 Pregnant +300 Lactating +500

    CALORIC REQUIREMENT FOR PARENTERAL NUTRITION Neonate 90-120 cal/kg 20 kg 1500 + 20 cal/kg in excess of 20 kg FAT requirement in parenteral nutrition 0-12 mos 2 g/kg/day 1-8 yr 4 g/kg/day > 8 yr 2.5 g/kg/day CARBOHYDRATE reqt VLBW ( 8 yr 1-1.5 NORMAL ELECTROLYTE REQT Na 2-4 meq/kg/day K 2-3 Cl 2-3 Mg 0.25-0.5 Ca Infants 300-400 mg/kg/day Children 100-200 Adolescent 50-100 Phosphorous Infants 1-1.5 mmol/kg/day Children 1 Adolescent 0.5-1 F75 DIET: 75 cal/100 cc Skimmed milk powder 25g Veg. oil 20g Sugar 60g Rice (cereal) powder 60g Water to make 1,000 ml *give 100-130 cc/kg/day F100 DIET: 100 cal/100 cc Skimmed milk powder 80g Veg. oil 60g Sugar 50g Water to make 1,000 ml * minimum daily intake of 120-200 ml/kg RESOMAL (ORS for malnourished patients) Dilute 1 L of ORS with 1 L water Add 45 ml of 10% KCl Add 50 g sucrose Composition: Na 45 mmol/L K 40 mmol/L Sugar 25 g/L

    FEEDING REGIMEN (ENTERAL NUTRITION) 1. Intermittent/bolus more physiologic - should only be used for gastric feed - start at 1-5 ml/kg/bolus - every 3-6 hrs - deliver over 30-120 min (2 hrs)

    2. Continuous better tolerated in px w/ feeding intolerance & significant GER - for critically ill px - start 1-2 ml/kg/hr in child/adol - can be increased by 1-2 ml/hr - concentration shld be inc before volume

    NUTRITIONAL GUIDELINE Energy caloric goal = 125% RDA based on wt/ht at 50th percentile * glucose polymer to in to 24-27 cal/mg formula * MCT infant formula * MCT oil supplement 1-2 ml/k/d 2-4 doses * supplemental nighttime NGT feeding Essential Fatty acids corn oil Protein intake (infants) 2-3 g/k/d (child) 0.5-1 g/k/d

    Children Hospital Formulary - started at 10-20 cc/kg/d as bolus or cont. - advance by

  • Pedia Notes Page 12 /epcapul

    Per 100 ml CHON 3g CHO 13.3g COOH 3.9 g

    PEDIASURE standard dilute Per 100 ml Caloric content 100cal CHON 3g COOH 4.78g CHO 43.8g * 190 ml of water + 5 scoops to make 225 ml

    MICRONUTRIENTS Vitamin A single dose < 6mos 50,000 IU 6-12 mos 100,000 IU > 12 mos 200,000 IU Zinc 1mg/kg/d Copper (infants) 0.2-0.6 mg/day (child/adol) 1-2 mg/day MgSO4 50% - 2ml IM/SQ Folic acid 5 ucg/kg/d Iron to start only in the 2nd week of illness when infection is better controlled at a dose of 3mg/kg/d MICRONUTRIENTS FOR UPBUILDING Vitamin A Folic Acid 800 ucg/prep (5 ucg/kg/d) D1-LD 5 mg or 5 tabs D2 1 mg or 1 tab Zinc 1-2 mg/kg/d Copper 0.2-0.6 mg/d (infant) 1-2 mg/d (children) FOR ACUTE DIARRHEA Zinc 6mo : 20 mg/d for 10-14 days

    Test dose for Intralipid < 5kg : 0.1 g/kg x 1 hr > 5kg 0.01 g/min x 10-15 min

    TOTAL PARENTERAL NUTRITION (TPN) amino acids make fluid D7.5/D10 NaCl (2.5 meq/ml) 3 meq/kg KCl (2 meq/ml) 2 meq/kg Ca gluconate 10% - wt x 3, or wt x 300/100 MgSO4 (25% 1meq/ml, 50% 2meq/ml) -0.2 meq/kg

    NEONATAL CHOLESTASIS CHOLERETIC DRUGS UDCA 250mg/tab, 15-45 mkd Rifampicin 5mkd Cholestyramine 4-16 g/d Phenobarital 3-10 mkd Vitamin A 2,500-25,000 IU/day Clusivol drops /0.6ml = 4,000 IU Clusivol syrup /5ml = 2,500 IU Nutrilin drops /ml = 5,000 IU Nutrilin syrup /5ml = 1,500 IU Enervon C drops /ml = 3,500 IU Enervon C syrup /5ml = 100 IU Vitamin D 400-1,200 IU/day as D3 Clusivol drops /0.6ml = 400 IU Clusivol syrup /5ml = 500 IU Nutrilin drops /ml = 333.33 IU Nutrilin syrup /5ml = 100 IU Enervon C drops /ml = 200 IU Enervon C syrup /5ml = 200 IU Rocaltrol (Calcitriol) 0.25ucg/cap = 0.05-0.2 ucg/kg/d Vitamin E 15mg/d -200 mg/kg/d or alpha tocopherol acetate (squibb) [100 or 200 or 400 IU/cap] 25-200 IU/kg/d, 1 cap at least q5 days in infants 100 IU = 65 mg

    Vitamin K 1-5 mg/d Ca (elemental) 50-200 mg/kg/d 25-100 mg/kg/d Up to 800-200 mg/d Ca Sandoz /5ml =110mg elemental Ca Sandoz /tab =500mg elemental *Corrected Ca = (40-actual)x.02 + actual Phosphorous (elemental) 25-50 mg/kg/d up to 500 mg/d Mg Mg oxide 1-2 meq/kg/d PO deficiency: serum Mg 2sec is pathologic - >3 sec indicate risk for bleeding - evaluates extrinsic pathway - prolonged when facter 1,2,5,7,10 deficient - if prolonged in chronic liver dse suggest poor prognosis NORMAL PT/PTT IN HEALTHY PRETERM PT PTT Day1 13(10.6-16.2) 53(27.5-79.4) 5 12.5(10-15.3) 50.5(26.9-74) 30 11.8(10-13.6) 44.7(26.9-62.5) 90 12.3(10-14.6) 37.5(28.3-50.7) 180 12.5(10-15) 37.5(21.7-53.3) Adult 12.4(10.8-13.9) 33.5(26.6-40.3) Factor VIII- non-hepatic

  • Pedia Notes Page 13 /epcapul

    - only factor not made in liver - can be used to differentiate liver dse fr DIC (may be N or inc in liver dse) Vit K deficiencies Give Vit K 1mg/kg IM/IV, min: 1mg in FT Measure PT 4-6 hrs after ROLE OF LIVER IN COAGULATION produce coag factors except von willebrand produce & brkdown factors integral to fibrinolysis eg plasminogen & plasminogen activator clears activated clotting factors fr circ

    Albumin principal serum protein - synthesized only in rough endoplasmic reticulum of hepatocytes at 150 mg/k/d - half life: 20 d - maintains colloid osmotic pressure - bind/carrier of bilirubin, Ca, other drugs - in pts w/ ascites: may be dec due to inc in the distribution vol rather than dec synthesis - often sign of chronic rather than acute liver dse (since long half life) Other nonhepatic causes of low albumin poor nutrition, nephrotic (urine loss), protein losing enteropathies (fr gut), inc degradation rate (poorly understood)

    SERUM ALBUMIN LEVELS g/dL +1 SD 1-3mos 3.4 0.72 4-6mos 3.46 0.36 7-12 mo 3.62 0.6 13-24 mo 3.63 0.8 25-36mo 4.11 0.78 3-8yr 4 0.65 9-16 yr 4.25 0.7

    serum albumin and PT are most impt parameters need liver transplant

    HEPATOPULMONARY SYNDROME 1. Hypoxemia 2. Intrapulmonic right to left shunting of blood 3. Liver disease Patient with chronic liver disease with history of shortness of breath or exercise inteolerance and clinical examination findings of cyanosis (particularly of the lips & fingers), digital clubbing, and O2 sats ferric absorbed - Increases absorption: Gastric acid, some sugars, aa, Bile - Decreased absorption: Oxalate, phosphates - Stimulate inc absorption: 1. iron def, 2. hypoxia, 3. erythropoiesis

    HEMORRHOIDS Daflon micronized purified flavonoid fraction chronic conditions & venous insufficiency: 2 tabs/day acute hemorrhoidal attacks: 3tabs BID x 4 d, 2 tabs BID x 3 days

    Antibiotics in Gut Obstruction (rationale) Blood flow to the obstructed bowl decreases as the bowel dilates Blood flow is shifted away from the mucosa with loss of mucosal

    integrity Bacteria proliferates in the stagnant bowel with a predominance of

    coliforms and anaerobes

    Rapid proliferation of bacteria coupled with loss of mucosal integrity allows bacterial translocation across the bowel wall potentially resulting in endotoxinemia, bacteremia and sepsis

    Bowel gas Air is usually demonstrable radiographically in the stomach of a

    normal infant immediately after birth Within 1 hour, air may reach the proximal portion of the small intestine

    and segments of the colon Air may become visible in the distal parts of the colon as early as the

    3rd hour or as late as 18 hours

    HEMATOLOGY and ONCOLOGY

    ANEMIA Measured Hgb > 2 SD below the mean for age Age Mean -2SD 1 mo 14 10 2 mo 11.5 9 3-6 mo 11.5 9.5 .5-2 y 12 10.5 2-6 y 12.5 11.5 6-12 y 13.5 11.5 12-18 M 14.5 13 F 14 12 18-49 M 15.5 13.5 F 14 12

    MCV measures the average volume of a red blood cell categorizes red blood cells by size. Formula (2-10 yrs old) Lower limit: 70 fL + age in years Upper limit: 84 fL + ( age in yrs x 0.6 ), until upper limit of 96 is reached Whats the MCV range? Give LL and UL of a 7 years old. Answer: LL: 77 fL; UL: 88.2 fL

    RETICULOCYTE COUNT Measures erythrocyte production Expressed as % of circulating rbcs Take up reticulin stain (supravital): bec of inc RNA N = 0.5 % to 1.5 % or = .005 to .015

    Reticulocyte index Anemic patient --> increased retic so have to correct: retic observed x px Hct / 0.45 Example: Hb 50 Hct 0.15 Retic count=.045= 4.5 % Corrected retic = 4.5% x .15/.45 = 1.5 % ( N = 0.5-1.5%)

    Absolute Retic Count More accurate Compute as ff: RBC (in n x 1012 ) x # retic/1000 rbc x 1000 Normal = 40,000 100,000/uL Example: Compute for absolute retic count : Hb 90 RBC 3 x 1012 /L Retic .015 Answer: 45,000 retics / uL

    IRON DEFICIENCY ANEMIA - microcytic, hypochromic, increased RDW Therapy: daily total dose of 4-6mg/kg of elemental iron in 3 divided doses

  • Pedia Notes Page 14 /epcapul

    Response to therapy Time after Iron administration Response

    12-24hr Replacement of intracellular iron enzyme; subjective improvement, decreased irritability, increased appetite

    24-48 hrs Initial bone marrow response; erythroid heperplasia

    48-72 hrs Reticulocytosis, peaking at 5-7 days

    4-30 days Increase in hemoglobin levels 1-3 months Repletion of stores

    NEUTROPENIA Neutropenia- decrease in the absolute neutrophil count (ANC) ANC= WBC x (neutrophils and bands) Neutropenia < 1000/mm3 infants between 2 weeks and 1 year < 1500/mm3 beyond 1 year of age Severe Neutropenia: ANC less than 500/mm3 Moderate Neutropenia: ANC 500-1000/mm3 Mild Neutropenia:ANC 1000-15000/mm3 Transient- < 8weeks Chronic->8 weeks Clinical Features high fever, chills, severe prostration, and irritability extensive necrotic and ulcerative lesions: oropharyngeal and nasal tissues , skin, gastrointestinal tract , vagina and uterus Gram-negative septicemia ANC Hyperuricemia >Hyperkalemia >Hyperphosphatemia >Hypocalcemia >Hypercalcemia >Renal failure

    Hydration -Should be given at the rate of 3000mL/m2/day to maintain urine output of >100mL/m2/hr or >5mL/kg/hr Alkalinization of urine -Increase solubility of urates -maintain urine pH 6.5 to 7.5 -maintain urine specific gravity 38.5C or 2 SD above normal for age in the absence of external stimulus, long-term drug or painful stimulus, or otherwise unexplained persistent elevations over 0.5-4 hours period OR for children 6 hours 6 hours Configuration Stellate, avulsion Linear Depth >1cm 1 cm Mechanism of injury Missile, crush, burn,

    frostbite Sharp surface (glass, knife)

    Dentalized Present Absent conataminants (dirt) Present Absent Neonatal tetanus suggested system of scoring to assess prognosis at time of admission and subsequently The severity of the disease is inversely proportionate to the score: 0 recovery improbable; 15 recovery Reassessment of score should be done 24 hourly An unchanged or lower score at subsequent assessment signified ineffective management or complications and calls for modification of treatment

  • Pedia Notes Page 15 /epcapul

    Score 0 1 2 3 Age of onset of sx in days (incubation period)

    1-4 5-8 9-12 >12

    Interval between first symptom and fisrt spasm in hours (onset interval)

    48 No spontaneous spasms

    Spasms: duration in minutes

    Persistent prolonged

    >2 3 >2-1-24 hours old

    For children 7 years Td preferred to tetanus toxoid alone 2 Yes if >10 years since last booster

    3 Yes if > 5 years since last booster

    Treatment of Tetanus 1. Immunization Passive immunization (TIG) preferably 3,000-6,000 u IM although experts claim 500 u is just as effective Alternate drug:Tetanus antitoxin 500u/kg body weight or 5,000 u newborn, 10,000 u children, 20,000 u adults; intravenously and the next intramuscularly Active immunization Tetanus toxoid. First dose admission; second dose discharge; third dose 6 months later 2. Antibiotics Metronidazole 30mkd Q6 X 10-14 days oral or iv Pen G: Neonate 100,000 u/kg/day Q8 Children 200,000 u/kg/day 4-6 doses Adults 1Mu IV Q6 X 15 days 3. Control of muscular spasms Prognosis: Serious case fatality rate: 44-55%; Neonatal tetanus 60%

    NEONATOLOGY

    NEONATAL RESUSCITATION PROGRAM Tube size (mm) inside

    diameter Weight (kg) Gestational age

    (weeks) 2.5 38

    Laryngoscope: Size 0 preterm Size 1 term

    Weight (kg) Depth of insertion (cm from upper lip)

    24hrs,

  • Pedia Notes Page 16 /epcapul

    Breastfeeding Jaundice - exaggeration of physiologic jaundice of the newborn as a result of inadequate breastmilk intake or insufficient breastfeeding frequency starvation jaundice - free fatty acids inhibition of glucuronyl transferase activity unconjugated bilirubin Management: increase breastfeeding frequency; breastfeeding should not be discontinued

    Breastmilk Jaundice - results from the presence of a yet unidentified factor which further increases absorption of unconjugated bilirubin in newborn Management: discontinue breastfeeding for 24-48 hours Jaundice disappears: breastmilk induced Jaundice persists: pathologic jaundice further diagnosis

    PHOTOTHERAPY Not for treatment of hyperbilirubinemia It only decreases the need for exchange transfusion Criteria to rule out physiologic jaundice Clinical jaundice 5 mg/dl/day (85 mmol/L/day) TSB >12 mg/dl in FT, >15mg/dl in PT Jaundice >1week in FT, >2 weeks in PT DB >2 mg/dl or >20% of TSB To establish etiology of hyperbilirubinemia Baseline TB, DB, IB CBC with PC PBS, Coombs test,Reticulocyte count Mothers and babys blood type Skin color is not reliable Policy on Improvised Bilirubin Lights 10 fluorescent bulbs at 20 watts each Distance of 20 inches or 50cm from the patient Duration of use should not be more than 2000 hours Stop photo when: 130.7 (FT); 10.71.2 (PT) Prophylactic phototherapy Extensive bruisingin VLBW Diagnosis of hemolytic disease Reminders: Determine bilirubin levels every 8-12 hours Follow fluid balance carefully. Increase TFI if on phototherapy. Avoid if with liver disease or obstructive jaundice (DB >2mg/dl) because of risk of bronze baby syndrome Anticipate revound of 25% after phototherapy is discontinued Cover eyes & genitals with black cloth to protect from radiation Discontinue if patient becomes hyperthermic Potential Complications Impaired maternal-fetal bonding Retinal damage Diarrhea / ileus Dehydration Hyperthermia Skin rashes Bronze baby syndrome

    EXCHANGE TRANSFUSION Indications Correction of anemia Removal of sensitized RBCs Reduction of TSB Immune thrombocytopenia Equivocal efficacy: Treatment of sepsis, RDS, DIC Consider for the following conditions: Rh incompatibility ABO incompatibility with eigher bilirubin >20 mg/dl or lesser if clinical condition warrants or evidence of kernicterus at any level Hyperbilirubinemia due to other causes: VLBW infants, BW in kg X 10 exchange necessary Metabolic-toxic conditions: hyperammonemia in UCDs and drug overdose Techniques for exchange transfusion:

    a. Prepare fresh whole blood (mothers blood type if ABO incompatibility): should be cross-mathced with maternal blood if ABO/Rh incompatibility

    b. Place a UVC after aspirating gastric contents c. A two-volume exchange (DVET): 80-85% turnover. A one-

    volume exchange only 60%. d. Allow 1-2 minute per cycle; hour per volume, so 1 hour for

    DVET e. Pre exchange studies: CBC with PC< bilirubin f. Post exchange studies: CBC with PC, bilirubin, RBS, K, Ca

    taken 6-12 hours post exchange, blood CS is controversial g. A CVP of 5-8 cm H2O be maintained at all times h. Keep thermoregulated during procedure i. Resume feeds 4 hours after exchange

    Calculations Total blood volume (TBV) Term or >1kg: 80cc/kg Preterm or 15 signifies severe respiratory compromise 30-35 failure to respond to the existing mode of ventilator support >40 80% risk of death, ECMO

    Screening ROP 4-6 weeks chronologic age, 31-33 wks PCA 1500, AOG 28 weeks, unstable course Hearing wt>1.5, off vent/meds 10-15mL is considered extensive.

    NECROTiZING ENTEROCOLITIS Risk Factors 5 Is Ischemia Immaturity Immunologic Infection Intake

  • Pedia Notes Page 17 /epcapul

    Stage Systemic Intestinal Radiographic Stage I NEC suspect

    Nonspecific: apnea, decreased HR, lethargy, temperature instability

    Gastric residuals; guiac + stools

    Nonspecific

    Stage IIA Mild NEC

    Same Prominent abdominal distention tenderness, (-) bowel sounds, gross blood in stools

    Ileus, dilated bowel loops, focal areas of pneumatosis intestinalis

    Stage IIB Moderate NEC

    Mild acidosis, APC

    Abdominal wall edema, tenderness palpable mass

    Extensive pneumatosis intestinalis

    Stage IIIA Advanced NEC

    Respiratory / Metabolic acidosis, assis vent for apnea, decreased BP, decreased UP, neutropenia, DIC

    Spreading edema, erythema, abdominal induration

    Prominent ascites, persistent sentinel loops with no perforation

    Stage IIIB Deteriorating VS and laboratory indices

    Pentoxyfylline Preparation: 300mg/15mL Therapeutic dose 6mg/mL Example 1.2 kg X = 6mg/kg X 1.2kg X 6 = 43.2 or ~ 44 X = 44mg (15mg/300mg) = 2.2 mL Order: Give 3.8 mL pNSS + 2.2 mL Pentoxifylline to make 6mL to run at 1cc/hr X 6 hrs OD for 6 days

    RESPIRATORY DISTRESS SYNDROME I / HYALINE MEMBRANE DISEASE Bonsel Grading (Radiographic)

    Severity Grade Reticulogram Cardiothymic shadow

    Air Bronchogram

    Mild 1 Mild, hazy generalized

    Clearly defined

    Perihilar within CT shadow

    2 Moderate / generalized

    Still discernible

    Just past CT borders

    Moderate 3 Heavier and more confluent

    Hazy, barely discernible

    Past 2/3 lung

    Severe 4 White out lung fields

    Up to lung periphery

    Cardiac borders no longer visible

    NEPHROLOGY

    OSMOLALITY Osmolality = 2(Na) + BUN/18 + Glucose/2.8 nv: 220-320 nCVP: 5-10cm

    ARTERIAL BLOOD GAS Compute for the pH Compute for the expected bicarbonate when it is abnormal Primary Disorder

    Expected Change HCO3 pCO2 SBE

    Metabolic acidosis

    26 (0.7xHCO3) + (212)

    5

    Acute Respi Acidosis

    [(pCO2-40) 10] + 24

    >45 or pH = 0.008 x (pCO2-40)

    =0

    Chronic Respi Acid

    [(pCO2-40) 3] +24

    >45 or pH = 0.003 x (pCO2-40)

    0.4 x (pCO2-40)

    Acute Respi Alkalosis

    [(40-pCO2) 5] +24

  • Pedia Notes Page 18 /epcapul

    RESP ACIDOSIS WITH METABOLIC ACIDOSIS

    If actual HCO3 > expected HCO3 RESP ACIDOSIS WITH METABOLIC

    ALKALOSIS Respiratory Acidosis

    pH 45 NOTE: pH and paCO2 move in opposite direction Compute for expected pH

    Acute resp acidosis, uncompensated Compensated chronic respiratory acidosis Partially compensated respiratory acidosis

    If actual pH > 0.008 X pCO2, then compute for expected HCO3 concomittant metab acidosis or metab alkalosis

    pH >7.45 ALKALOSIS

    paCO2 0.008 but 0.017 X pCO2 Overlapping Metabolic derangement:

    RESP ACIDOSIS WITH METABOLIC ACIDOSIS OR RESP ACIDOSIS WITH METABOLIC ALKALOSIS

    If actual pH >0.017 X pCO2 - Overlapping Metab acidosis or alkalosis? So, Compute for expected HCO3

    If actual HCO3 < expected HCO3 RESP ACIDOSIS WITH METABOLIC

    ACIDOSIS If actual HCO3 > expected HCO3

    RESP ACIDOSIS WITH METABOLIC ALKALOSIS

    Respiratory Alkalosis pH >7.46, pCO2 0.017 X pCO2, then compute for expected HCO3 concomittant metab acidosis or metab alkalosis

    Estimated GFR = Ht (cm)x 0.5(children/adol girls) or 0.7 (Adol boys) Serum creatinine mg/dL Estimated GFR (mL/min/1.73m2)=kL/Pcr L (length/height, cm) Pcr- plasma creatinine k- constant k LBW during first year of life 0.33 Term AGA during first year of life 0.45 Children and Adolescent girls 0.55 Adolescent boys 0.70

    Creatinine Clearance (mL/min/1.73m2) =Urine cr x Urine vol x 1.73 Plasma cr 1440 BSA

    Normal Values of GFR Age GFR (mean)

    mL/min/1.73m2 Range mL/min/1.73m2

    Neonates 34wk gestational age 2-8 days 4-28 days 30-90 days 1-6 mo 6-12 mo 12-19 mo 2 yr-adult

    11 20 50

    39 47 58 7 103 127 127

    11-15 15-28 40-65

    17-60 26-68 30-86 39-114 49-157 62-191 89-165

    Laboratory Indices for Prerenal vs Intrinsic Acute Renal Failure Index Prerenal Intrinsic Renal Specific gravity Urine osmolality (mOsm) Urine Sodium(meq/L) FENa (%) Blood urea nitrogen / Creatinine

    >1.020 >500

  • Pedia Notes Page 19 /epcapul

    Acute Glomerulonephritis Ssx: edema (facial or bipedal), hypertension, hematuria, oliguria Labs:

    urinalysis with RBC morphology (mild hematuria RBC 1-2 with dysmorphic RBC)

    C3 ASO CBC BUN, Crea NO ultrasound nonspecidifc

    Treatment: Furosemide (3) Q6 Continuous Furosemide drip 0.5 mg/kg/hr

    Rate = WT X 0.5 Preparation: 100mg Furosemide + 100cc D5W to make 1mg/mL

    Nephrotic Syndrome Ssx: Generalized edema, heavy proteinuria, hypoalbuminemia Diagnostics:

    Urinalysis Albumin 24 hour urine collection with urine protein and urine creatinine NO ultrasound

    Protein spillage: Significant proteinuria: 4-40mg/m2/hr Nephrotic range or heavy proteinuria: >40 Total protein spillage

    Management Diuretics

    Bumeanide 1mg/tab 1 tab BID to Q6 HCTX 25 or 50mg tab BID

    Antibiotics Penicillin G if with infection Target Group A beta-hemolytic Streptococcus

    Steroids Prednisone:

    Initiation: 60mg/m2/day Max of 60mg/day 20mg tabs 3 tabs max Check response in 7-10 dyas (half life of prednisone) May be given for 2-4 weeks; Maximum of 10 weeks If (-)n protein or repeat UA with decreased protein, may shift

    to maintenance Maintenance phase

    40mg/m2 every other day after breakfast to counteract cortisol surge producing less side efects

    Given for 6-0 months Taper slowly every 2 weeks until with (-) protein

    Hydrocortisone IV

    Urinary Tract Infection Inquire regarding manner of collection of urine sample for urinalysis

    Wee bag increased sensitivity: if urinalysis is negative then we are sure it is not UTI

    Midstream catch Clean catch

    Diagnostics: Ultrasound Dimercaptosuccinic acid scan (DMSA) check renal scarring. If

    there is no scarring, then it is not reflux. Voiding cystourethreogram (VCUG) Urodynamic studies

    Medications: Cefuroxime, Co-amoxiclav Duration: if culture (-), treat for 7 days; if culture (+) treat for 14 days

    Renal Support Medications CaCO3 50-100mkd TID (Prep 500mg, 650mg) NaHCO3 1-3 meqs/kg/day (BID-QID) (Prep 325mg/tab, 450mg/tab = 7.7 meqs) FeSO4 3-6 mkd Erythropoietin 500mkdose (prep 2000 u, 4000 u)

    Cyclphosphamide Prehydration D5 0.3 NaCL : BSA X 3000mL to run in 1 hours Cyclophosphamide (500mg/BSA + 40-60% Mesna dilute in D5W to make 100mL to run in 1 hour Posthydration: FM X 6 hours (D5 0.3NaCl)

    Peritocat / Stiff Cath Insertion 1. Strict asepsis 2. Instill Lidocaine in 2 fingerbreaths midline below the umbilicus 3. Using IV needle gauge 16 (large bore), insert perpendicular/vertical once give is felt, withdraw needle slowly and continue insertion of IV cannula into peritoneum 4. Induce ascites using Eruopersol 1.5% until boardlike rigidity of abdomen is felt 5. Withdraw IV cannula and insert stiff cathe in a screwing motion into the peritoneum. Once with give withdraw needle and insert eigher to R or L of abdomen (measure depth of peritoneum catheter from umbilicus to symphysis pubis) 6. Once in place, connect extension tube and draw fluid. 7. Stabilize peritoneal catheter by suturing continuously at the 3, 6, 9, 12 oclock position and approximately below pericath marker and tie. 8. Clean with betadine

    NEUROLOGY GCS Eye opening Verbal Motor Spont Speech Pain None

    4 3 2 1

    Oriented/Smiles Confused/ Consolable Words/ Inconsolable Sounds/ Grunts None

    5 4

    3

    2 1

    Obeys Localizes Withdraws Flexion Extension None

    6 5 4 3 2 1

    nICP: Infants 5mmHg; Children 6-13; Adults 5-15mmHg upper limit: 20mmHg CPP=MAP-ICP; >50-70mmHg

    Cerebral Dominance Dominant Hemisphere handedness; perception of language and speech, writing Nondominant Hemisphere spatial perception; recognition of faces and music

    Lentiform nucleus glovus pallidus + putamen Corpus striatum caudate nucleus + lentiform nucleus Neostriatum caudate nucleus + putamen

    Aphasia Expressive aphasia- Brocas area; destructive lesions in the left inferior frontal gyrus; loss of ability to produce speech Receptive aphasia Wernickes area; destructive lesions restricted to Wernickes speech area; loss of ability to understand the spoken and written word

    Abnormal Respiratory Patterns Cheyne-Stokes breathing- forebrain damage Central neurogenic hyperventilation- hypothalamic-midbrain damage Apnea; cluster breathing- lower pons Ataxic breathing- medulla

    Pupillary size and reaction Anisocoria- uncal herniation Small, reactive- metabolic, diencephalic compression Pinpoint- pons Midposition, fixed- midbrain Large, fixed- tectal

    Posturing Decorticate rigidity- flexor response in the arms with extension of the legs Localization: cerebral hemisphere Decerebrate rigidity- abnormal extensor response in the arms and legs

  • Pedia Notes Page 20 /epcapul

    Localization: bilateral diencephalic and hemisphere damage; upper brainstem injury Can be seen in the ff. conditions: Massive head trauma and cerebral hemorrhage Rostro-caudal deterioration Posterior fossa or cerebellar lesions Severe metabolic disorders- hepatic coma

    Holoprosencephaly Failure to form the paired cerebral hemispheres Lateral ventricles are represented by a single midline cavity

    Lissencephaly Defect in migration of the cerebral neurons Cortical gyri fail to develop Surface of the cerebral hemispheres is smooth with absence of normal cortical layers microscopically. Severe mental retardation

    Pachygyria Defect in the migration of the cerebral neurons Few and broad gyri Associated with a four-layer cortex that underlies thickened gyri

    Polymicrogyria Neuronal migration defect Excess of small and poorly developed cerebral gyri Most commonly sporadic, may be associated with Zellweger cerebro-hepato-renal syndrome Severe mental retardation, seizures

    Schizencephaly Unilateral or bilateral gray matter lined cleft of the lateral cerebral wall, extending from the periventricular zone to the meninges

    Hydranencephaly Congenital absences of cerebral hemispheres which are replaced by large CSF filled cavities Brainstem and basal ganglia are present and there may be rudiments of frontal and occipital cortex

    Chiari Malformations Chiari I Elongated peglike cerebellar tonsils displaced in the upper cervical canal 20-40% with associated syrinx Chiari II (Arnold-Chiari) Vermis, pons, medulla and an elongated fourth ventricle are displaced inferiorly into the cervical canal Myelomeningocoele in nearly 100% Chiari III Hindbrain herniation into a low occipital or high cervical encephalocoele in combination with features of chiari II Chiari IV Associated with cerebellar hypoplasias and dysplasias

    Dandy Walker Malformation Large posterior fossa Fourth ventricle floor present, ventricle open dorsally to large posterior fossa cyst Hydrocephalus in 80% Vermian, cerebellar hemispheric hypoplasia Brainstem may be hypoplastic, compressed

    Porencephaly Defect in the cerebral mantle resulting in a cyst-like expansion of the lateral ventricle Usually unilateral Usually secondary to local damage to the cerebrum, either during late fetal life or early infantile life

    Status Epilepticus a neurologic emergency wherein the patient develops generalized or partial seizures lasting for 30 minutes or longer, or a series of seizures wherein the patient does not regain consciousness in between seizures

    Refractory Status Epilepticus status epilepticus of more than 60 minutes, where adequate dosages of benzodiazepines, Phenobarbital and Phenytoin fail to terminate the seizure

    Intractable Epilepsy at least 1 seizure per month for at least 12 months, refractory to maximal, tolerable doses of at least 2 first line anticonvulsants, with compromised quality of life.

    Simple Febrile Seizure seizure characterized as generalized (usually tonic-clonic), lasting for less that 15 minutes and which does not recur within the same febrile illness.

    Complex Febrile Seizure seizure with partial onset, prolonged duration (lasting >10 or >15 minutes, both have been used) and recurrent (more than 1 seizure in a single illness episode, generally in 24=hr period).

    Myaesthenia Gravis Grade I weakness restricted to extraocular muscles Grade IIa Generalized mild weakness Grade IIb Generalized moderate weakness Grade III Generalized severe weakness Grade IV Life threatening weakness of respiratory muscles

    Hepatic Encephalopathy I Changes in behavior, minimal change in level of consciousness, altered sleep (hypersomnia, insomnia), inversed sleep cycle in the newborn II Spatiotemporal disorientation, drowsiness, inappropriate behavior, obvious asterixis III Marked confusion, stuporous, repond or not to auditory stimuli, decerebrate posturing to pain, asterixis usually absent IV comatose, unresponsive to pain, decorticate posturing

    Subacute Sclerosing Panencephalitis (SSPE) Stage IA Behavioral, cognitive and personality change (decreased school performance, attention / hyperactivity, inappropriate socially, sleep disturbance. Walking Stage IB Myoclonic spasm a periodic, focal, independent ambulation. Same mental / behavioral symptoms as IA. Stage IIA Further mental-behavioral deterioration. Myoclonic spasms periodic, generalized and synchronous, frequent. Can walk independently but doesnt because of drop spells. Stage IIB Apraxia, agnosias, language difficulties. Motor signs spasticity, ataxia. Ambulatory with assistance. Stage IIIA Speaking less, visual difficulties, no ADLs. Sits up independently, may stand, no independent ambulation. Myolonic spasms frequent, multifocal, short inter-spasm intervals (3-5seconds); long duration (3-4seconds). May have seizures. Stage IIIB No spontaneous speech, poor verbal comprehension, may be blind. Myoclonic spasms same as in IIIA. Bedridden, dysphagia, may have to be fed by NG tube. No EEG delta background activity. PSWC (periodic slow wave complexes) often obscured in background. Movement disorder may appear (chorea-ballismus-athetosis). Stage IV No myoclonic spasms. EEG very low voltage background activity. No PSWC. Patient in neurovegetative state.

    Acetazolamide cerebral vasodilator; transiently worsen intracranial hypertension. Contraindicated in closed head injury

  • Pedia Notes Page 21 /epcapul

    PULMONOLOGY

    RR 65 respiratory compromise MAP=PIP-PEEP x IT x RR/60 + PEEP; nv 35 for 5-6hrs 1 criterion for ECMO O2 content (CAO2) in ml/dL= Hgb in g/dL x 1.34 x O2 Sat in decimal + PO2 x 0.003; nv 18-20 AV difference (AVDO2) = CAO2 CVO2; nv 5mL/ 100dL O2 extraction = CAO2 CVO2/ CAO2; nv 0.25 Shunt fraction = pAO2 CAO2/ pAO2 CVO2; nv

  • Pedia Notes Page 22 /epcapul

    o Aspiration of gastric contents o Pulmonary contusion o Fat emboli o Near-drowning o Inhalational injury o Reperfusion pulmonary edema

    Indirect Lung Injury o Sepsis o Severe trauma with shock and multiple transfusions o Cardiopulmonary bypass o Drug overdose o Acute pancreatitis o Transfusions with blood products (TRALI)

    General Measures Careful search for underlying cause Prevention or early treatment of nosocomial infection Adequate nutrition preferably enteral Prevention of GI bleeding Prevention of thromboembolism Specific Measures o To decrease ventilator-induced lung injury: Mechanical ventilation o To address surfactant deficiency and dysfunction: Surfactant therapy o To improve V/Q mismatch: Prone positioning o Inhaled nitric oxide and other vasodilators o To decrease pulmonary edema: Fluid and hemodynamic

    management; b-agonist (?) o To decrease inflammation: Glucocorticoids and other antiinflammatory

    agents

    RHEUMATOLOGY

    SYSTEMIC LUPUS ERYTHEMATOSUS 1997 Revised Classification Criteria CRITERION DEFINITION Malar rash Fixed erythema, flat or raised, over the malar

    eminences, tending to spare the nasolabial folds Discoid rash Erythematous raised patches with adherent keratotic

    scaling and follicular plugging; atrophic scarring may occur in older lesions

    Photosensitivity Rash as a result of unusual reaction to sunlight (elicited by patient history or physician observation)

    Oral ulcers Oral or nasopharyngeal ulceration, usually painless, observed by a physician

    Arthritis Non-erosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling, or effusion

    Serositis Pleuritis:convincing history of pleuritic pain or rub heard by a physician or evidence of pleural effusion OR Pericarditis:documented by ECG or rub or evidence of pericardial effusion

    Renal disorder Persistent proteinuria >0.5 g/day or >3-plus (+ + +) if quantitation not performed OR Cellular casts: may be red blood cell, hemoglobin, granular, tubular, or mixed

    Neurologic disorder

    Seizures:in the absence of offending drugs or known metabolic derangements (e.g., uremia, ketoacidosis, or electrolyte imbalance) OR Psychosis:in the absence of offending drugs or known metabolic derangements (e.g., uremia, ketoacidosis, or electrolyte imbalance)

    Hematologic disorder

    Hemolytic anemia, with reticulocytosis OR Leukopenia:

  • Pedia Notes Page 23 /epcapul

    MEDICATIONS

    Amphotericin B Amphotericin B (1mkd) 50mg/vial + 10mL sterile water to make a 5m/mL stock solution. Give 3mg or 0.6mL (5mg/mL stock solution) + 30mL D5W to make a 0.1 mg/mL solution. Infuse over 6 hours OD.

    Adenosine for SVT 0.1mg/kg (max 1st dose 6mg, 2nd 12mg) Albumin 0.5-1gm/k/dose x 30-120mins (max 6gm/k/day) Aminophylline 6mkLD x 20mins; MD 1-2mkdose q6-8 Amiodarone 5mkdose x 20-60min (VT), bolus (VF/Pulseless VT) Atropine 0.01-0.02mg/k (min0.1; max0.5mg); may rpt once Bumetanide 0.015mg-0.1mkdose (max: 10mg/day) Calcium gluc 100mkdose x 1hr (max 3gm); 200-500mkd/q6 Chloral hydrate 25-100mkdose Dexamethasone 1-2mkLD, MD 1-1.5mkd/q4-q6 (max 16mg/day) for cerebral edema; 0.5-2mkd/q6 for airway edema Dobutamine 2.5-20mcg/kg/min; rate= wt x dose/16.6 Dopamine 2-20mcg/kg/min; rate= wt x dose/13.3 Epinephrine 0.01ml/k SC (allergy/asthma); drip 0.1-1mcg/k/min; racemic 0.5ml/kg in 3mlNSS (max 2.5ml4yo) Etomidate -.2-0.4mg/kg Fentanyl 1-2mcg/kg (for BP&head injury) Furosemide 0.5-2mkdose (max: 6mkdose) Granisetron 10-20mcg/k/dose Hydralazine 0.1-0.2mkdose q4-6 (max 20mg/dose) Hydrocortisone 4-8mk LD (max 250mg); MD 8mkd/q6 (asthma), 1-5mkd/q12-OD (allergy) Ipratropium bromide 0.25-0.5mg/dose TID-QID Ketamine 1-4mg/kg Ketorolac 0.5mkdose IV q6 (max 30mg/dose) Labetalol 0.3-3mg/kg/hr infusion Lidocaine for wide complex tach 1-2mg/kg Mannitol 0.5gm/k or 2.5cc/k; 1gm/k or 5cc/k MgSO4 25-75mkdose x 20mins q4-6 (max 2gm) Midazolam 0.05-0.1mkdose; 1-5mcg/k/min Milrinone 50mcg/k bolus x 15mins; 0.5-1mcg/k/min infusion Morphine 0.1-0.2mkdose q2-4 (max 15mg/dose) Nicardipine 1-3mcg/k/min infusion Nifedipine 0.25-0.5mkdose q4-6 (max 10mkdose or 3mkd) Nitroglycerin 1-5mcg/k/min (max 20mcg/kg/min) Omeprazole 0.6-0.7mkdose OD-BID Phenobarbital 20mkLD, 5mkdose q30min (max 30mkLD) Phenytoin 20mkLD; MD: 5mkd/q12-q8 Prednisone 2mkd/OD-BID (max 80mg); taper if >5-7days Procainamide for VTach 15mg/kg (do not give w/ amiodarone) Propofol 2mg/kg Propranolol for Tet 0.15-0.25mkdose SIV; may rpt in15mins Prostaglandin E1 LD 0.05-0.1mcg/k/min; MD 0.005-0.04mcg/k/min Sodium bicarbonate 0.3 x wt x base deficit; max concentration for infusion 0.5meqs/mL; max rate 1meq/k/hr Spironolactone 1-3mkd/OD-QID Terbutaline 2-10mcg/k LD; 0.1-0.4mcg/k/min infusion Thiamine for Wernickes enceph 100mg IV x 1 then OD Thiopental 2-4mg/kg Tramadol 1-2mkdose q4 (max 500mg/dose) Tranexamic acid 25mkdose TID Vecuronium 0.1mkdose q1 or 0.05-0.07 mg/kg/hr infusion Vancomycin

    Example 3kg Vancomycin (15mkdose or 60mkd) 500mg/vial + 10mL sterile water to make 50mg/mL stock solution, give 45mg or 0.9mL (50mg/mL stock solution) + 9mL NSS to make 5mg/mL solution. Infuse over 1 hour Q6. Monitor for increased/decreased BP, tachycardia. If these appear, stop infusion and give Diphenhydramine 1mg/kg/dose IV.

    REFERENCES: Bambo Notes Nelson Textbook of Pediatrics Pedia Lectures PICU Lectures

    Pedia Notes EPCapul 4.0 /phil4:13