Lec.1
Pediatrics
6
th
stage
2016/8/14
Session notes
د.بسام
Shortness of breath :
Important question to ask about it in Hx :
Duration to know it is acute or chronic
If patient presented with recurrent pneumonia and received
antibiotics With no improvent think about Foreign body
aspiration
Asthma a common cause for recurrent admission
Using accessory muscle of respiration mainly sternocleidomastoid
muscle in respiratory distress called or described as ( Head noding
)
Frontal bossing is one of the features of rickets
Infant with breast feeding more liable to rickets
Vit. D defeciency patient more risky for asthma
Bowing of the leg during the period ( 8 – 24 ) monthes is
physiological
Delayed tooth eruption can be due to Rickets
Ask also about :
Bluish discoloration , whooping cough
Whooping cough :
There is rarely whooping cough in the 1
st
year of childhood life
Post – tussive emesis is not pathognomonic for whooping cough can
be presented in asthma , broncholities also
Ask about feeding , sleeping if there is disturbance , indicate severe
respiratory distress
Ask about convlusion , whooping cough lead to cerebral hypoxia , and
this the later cause convlusion
Hyponatremia due to water retention caused by (SIADH)
IN reveiw :
Renal :
Ask about urine output , dehydration , this dehydration in SOB caused by
either decreased water intake and fever with insensible loss through
sweating
In pre-natal history ask about if there is respiratory distress syndrome ?
Muconium aspiration , usage of mechanical ventlation ( may cause
bronco-pulmonary dysplasia )
Ask about Oligohydro-amina which lead to hypovoluemia and this end
by heart failure
Ask about polyhydro-amina because it cause chest compression and this
affect growth of lung which lead to hyopoplastic lung
Hypoplastic kidney in intrautrine life lead to oliogohydo-amina and
patient presented at birth with renal failure and metabolic acidosis
Feeding history :
Is there is any aspiration during feeding mostly caused by trecheo-
esophageal fistula (TEF) , diaphragmatic hernia , GERD , esophageal
dysmotility ( transient ) , cleft palate , in Cerebral palsy the swollowing is
affected
Past medical Hx :
Recurrent problems , asthma , heart failure , pnemonia
Family Hx :
Child contact with TB patients , cystic fibrosis
Social Hx :
Domestic animals , overcrowding , sewage , air conditioning
On exam :
Look for the face the child looks ill , or will
Color is cyanosis or not , looks for patient lying in asthma if severe cant
lie , check for tricod position in Sevre SOB
Sign of respiratory distess ( flaring of ala nasi , subcostal suprasternal
resscion , deviated trechea )
Check for hydration state , level of conciousness
Investigations:
CXR
Blood gas analysis ( po
2
normal ( 60-90) mmHg if < 60 mmHG , OR PCO
2
( 35-45) mmHg if > 45 mmHg patient need Mechanical ventilator
Neonatal Emergencies
:
Birth asphaxia
First of all the asphyxiated newborn baby should be put on a
resuscitation trolley where the baby put under a radiant heater to
avoid hypothermia then drying up of the baby, the head is positioned
down & slightly extended, the airway is cleared by suctioning, and
also gentle tactile stimulation provided (slapping the foot or rubbing
of the back).
If spontaneous respiration started and the cardiac output improved
where the color of the baby becoming pink, then there is no need
now to go onto further steps of resuscitation, but if these measures
fails to improve the condition of the baby and the heart rate is < 100
/min so we need:-
2- Positive pressure ventilation with a 100% oxygen is given through a
tightly fitted mask & bag for 15-30 sec, subsequent breaths are given
at a rate of 40-60 /min with pressure of 15- 20 cm water. Successful
ventilation is determined by good chest rise symmetric breath
sounds, improved pink color, heart rate of >100 /min, spontaneous
respiration and improved tone. If no response within 15-30 sec.
the next step is:- Ambu bag Traditionally, the inspired gas for
neonatal resuscitation has been 100% oxygen. Resuscitationwith
room air (or 30%) is equally effective and may reduce the risk of
hyperoxia, which is associated with decreased cerebral blood flow
and generation of oxygen free radicals. Currently 100% O2 is
recommended. Room air (or 30%) may become the preferred initial
gas for neonatal resuscitation in the future.
3- Insert an endotracheal tube and start to push an oxygen through
the tube by an ambu bag, if after 15-30 sec of doing that & the baby
does not improve: (no spontaneous respiration, heart rateis <
100/min, no improvement in the color of the baby, so the next step
is:-
4- Starting chest compression (cardiac compression to improve
circulation) the compression is exerted to the lower third of the
sternum at a rate of 120 per min. the ratio of compression to
ventilation is 3:1 simultaneously the color, the heart rate the
respiration and muscle tone should be assessed, if the baby did not
respond after 15- 30 sec of chest compression & oxygen supply
through an endotracheal tube then:-
5- An intravenous drugs are used after an insertion of an intravenous
(usually umbilical) catheter and as follows:-
1. Epinephrine 1/10000 (0.1-0.3) ml/kg IV or intratracheal is given for
asystole or for failure to respond to 30 sec of combined resuscitation
and the heart rate is < 60/min, this can be repeated every 5 min .
2. Volume expanders 10 - 20 ml/kg of (normal saline, blood, 5%
albumine, or ringers solution) should be given for
hypovolemia,pallor,E.M dissociation (weak pulses with norml heart
rate), history of blood loss, suspicion of septic shock, hypotension or
in poor response to resuscitation.
3. Sodium bicarbonate (1-2meq/kg) should be given slowly in case of
metabolic acidosis and resuscitation is prolonged.
4. Calcium gluconate (2-4 ml/kg of 10% solution) if there is evidence
of hypocalcemia.
5. Naloxone given in a dose of 0.1 mg/ kg repeated as needed when
there is CNS depression due to maternal narcotic analgesic
administration during labor which will results in respiratory
depression & failure to initiate spontaneous respiration. 6. Dopamine
or dobutamine may be given in a dose of 5-20 microgram / kg/ min.
this drug may be used in severe asphyxia when there is depressed
myocardial function
Kernictus
:
تفاصيل الموضوع موجودة في ملزمة
سشن
د.ربيع
Sepsis and meningitis :
Check for hyperthermia or hypothermia ( more common ) ,
lethargy , sclermatic skin ( hardening of subcutaneous tissue )
Urgently start with empirical antibiotics :
Either Ampicillin ( 300 mg/kg ) + Gentamicin for 2-3 weeks
Or 3
rd
generation cephlaosporin ( Cefoxime ) + gentamicin
Most common pathogen ( Group B steptococcus , E.coli ,
H.influanzae )
Neonatal sepsis carries poor prognosis ( high fatality rate )
Neonatal hypoglycemia
:
It is dagerous because it may end with brain damage
Risk factors are : hyperinsulenemia , premature baby , IUGR , low
birth weight , polycythemia
Can be presented with seizure , lethargic , apnea
Tx : dextrose 10% by IV infusion avoid > 10% can cause
thrombophilibitis
Initially start wit bolus dose 200-400 mg/kg
Maitenance 6 mg /kg
Avoid using bolus dose in Diabetic mothers with hypoglycemic
baby because lead to pancreatic overstimulation which result in
resistant hypoglyecmia
Hemorrhagic disease :
Check for petechea , melena , heamtemesis ,
Caused by clotting factor deficincy ( hepatic immaturity , vitamen
K deficency )
Vit . K deficiency result from insufficient amount of normal
intestinal flora
Patient with breating feeding more liable for Vit . K deficeincy
Tx : Vit. K replacement 5-7 unit , 1 unit prophylaxsis
If not stop give Fresh feozen plasma
Neonatal seizures
:
Stop convlusion urgently to avoid cerebral anoxia
Usually occur 12–48 hr after delivery
.
Can be generalized or focal, and tonic, clonic, or myoclonic
.
Subtle seizure patterns (lip-smacking, limb-cycling, eye deviation,
apnoeas, etc.) can be
difficult to identify or differentiate from other benign conditions that
may mimic seizures
Startle or Moro reflexes, normal jittery’ movements (fine, fast limb
movements that are
abated by holding affected limb), Sleep myoclonus (REM
movements).
Tx :
IV phenobarbital (10–20mg/kg bolus; give further 10–15mg if
seizures persist after 30min
;
maintenance dose 5mg/kg/day).
Non-accidental injury ( child abuse )
Check for :
Delay in seeking medical attention.
The details of the mechanism of injury are implausible, change
over time, or are inconsistent with the developmental stage of the
child.
Lack of concern by the person accompanying the child.
Abnormal behaviour or demeanour by the child e.g. withdrawn,
avoiding eye contact. This should be observed in the context of
the child's background – for example it is usual to avoid eye
contact in some Pacific cultures.
Direct disclosure by the child that the injury was deliberately
inflicted.
Bruises ,Thermal burns , multiple fractures showen by X-ray ,
Congenital malformation
:
Bilateral choanal atresia : presented with difficult feeding ,
cyanosis , during entery of catheter not pass or confirmed v=by CT
scan
Esophageal atresia
Neoanatal intestinal obstruction :
Cause gangrane sepsis death
Usullay result from dudonal atresia , imperfoated anus , volvulus and
malrotation
In upper intesinal obstrucion vomiting preceding the constipation in
lower intestinal intestinal obstruction constipation preceeding the
vomiting
Necroting enterocolitis :
Cardiac malformation:
TGA , critical coarctation of arota , hypoplastic right ventricles ,
tricuspid atresia
Presented with early birth cyanosis
If duct depended give prostaglandin to permit duct opening
Renal :
Hypoplastic or agensis of kidney treated by kidney transplantation
If urine not pass check for bladder may be due to posterior urethral
valve obstruction if the cause in the kidney may be pelvic uretiric
junction obstruction , mass ( teratoma )
-Meningiomyocele
More risky if leaking closed by surgery
Life threatening birth injury :
By forceps during delivery cause depressed skull fractures or
intra-cerebral hemorrhge ,
Subglyeal hemorrhage may result in hypovolumia
Check blood to exclude if there is bleeding tendency
Give the child BT or NS or any volume expander
-bilateral phrenic nerve palsy
Tranient and patient need assissted ventaltion
-splenic , hepatic injury :
Need urgent correction to stop bleeding
Check for ecchymosis , hypovolumia
Investigate by US
Bilaterla femural fracture
Congenital adrenal hypoplasia
In children with the more severe form of the disorder, symptoms
often develop within 2 or 3 weeks after birth.
Poor feeding or vomiting
Dehydration
Electrolyte changes (abnormal levels of sodium and potassium in
the blood)
Abnormal heart rhythm
Girls with the milder form will usually have normal female
reproductive organs (ovaries, uterus, and fallopian tubes). They may
also have the following changes:
Abnormal menstrual periods or failure to menstruate
Early appearance of pubic or armpit hair
Excessive hair growth or facial hair
Failure to menstruate
Some enlargement of the clitoris
Exams and Tests
Your child's health care provider will order certain tests. Common blood
tests include:
The goal of treatment is to return hormone levels to normal, or near
normal. This is done by taking a form of cortisol, most often
hydrocortisone. People may need additional doses of medicine
during times of stress, such as severe illness or surgery.