BODY TEMPERATURE Subnormal Normal Subfebrile Fever High fever Hyperpyrexia AGE Preterm Term 0-3 mo 3-6 mo 6-12 mo 1-3 yrs 3-6 yrs 6-12 yrs

12-17 yrs HR (bpm) 120-170 120-160 100-150 90-120 80-120 70-110 65-110 60-95 55-85 <36.6°C 37.4°C 35.7 – 38.0°C 38.0°C >39.5°C >42.0°C BP (mmHg) 55-75/35-45 65-85/45-55 65-85/45-55 70-90/50-65 80-100/55-65 90-105/55-70 95-110/60-75 100-120/60-75 110-135/65-85 RR (cpm) 40-70 30-60 35-55 30-45 25-40 20-30 20-25 14-22 12-18 RBC WBC PMNs Lymph Hgb Hct pH: pCO2: pO2: 7.35-7.45 35-45 80-100

ABG HCO3: B.E.: O2 sat: 22-26mEq/L +/- 2mEq/L 97%

ANTHROPOMETRIC MEASUREMENTS IDEAL BODY WEIGHT Age At Birth 3-12 mo 1-6 y 7-12 y Kilograms 3kg (Fil) 3.35kg (Cau) Age (mo) + 9 / 2 Age (y) x 2 + 8 Age (y) x 7 – 5 / 2 Pounds 7 Age (mo) + 10 (F) Age (mo) + 11 (C) Age (y) x 5 + 17 Age (y) x 7 + 5

NORMAL LABORATORY VALUES NB 4.8-7.1 9-30,000 61% 31% 14-24 44-64% Infant 3.8-5.5 6-17,500 61% 32% 11-20 35-49 Child 3.8-5. Adole M: 4.6-6.2 F: 4.2-5.4 5-10,000 6-10,000 60% 60% 30% 30% 11-16 M: 14-18 F: 12-16 31-46 M: 40-54 F: 37-47 150-450 150-450 0-2 0-2

Given Birth Weight: Age Using Birth Weight in Grams < 6 mo Age (mo) x 600 + birth weight (gm) 6-12 mo Age (mo) x 500 + birth weight (gm) Expected Body Weight (EBW): Term Age in days – 10 x 20 + Birth Weight Pre-Term Age in days – 14 x 15 + Birth Weight

Platelets 140-300 200-423 Ret 2.6-6.5 0.5-3.1

BP cuff should cover 2/3 of arm -: SMALL cuff: falsely high BP -: LARGE cuff: falsely low BP BMI BT CT PTT

COUNT (%) 1-5 min 1-6 5-8 min 5-8 12-20sec 12-14 1-6 5-8 12-14 1-6 5-8 12-14

Underweight Normal Overweight at risk Obese I Obese II

Asian <18.5 18.5 – 22.9 ≥ 23.0 23 – 24.9 25 – 29.9 ≥ 30 LENGTH / HEIGHT (50 cm)

Caucasian <18.5 18.5 – 24.9 25 – 29.9 30 – 39.9 >40

Age of Infant 4-5 months 1 year 2 years 3 years 5 years 7 years 10 years

Ideal Weight 2 x Birth Weight 3 x Birth Weight 4 x Birth Weight 5 x Birth Weight 6 x Birth Weight 7 x Birth Weight 10 x Birth Weight

APGAR Age Inches 20 30 Age x 2.5 + 30 At Birth 1y 6y Transverse-AP Diameter ratio 1.0 1.25 1.35 Inches Transverse = AP Transverse > AP Transverse >>> AP 0 Blue / Pale Absent (-) Response (-) Movement Absent 1 Pink body/ Blue extremities Slow (<100) Grimaces Some flexion / extension Slow / Irregular 2 Completely pink > 100 Coughs, Sneezes, Cries Active movement Good, strong cry

Age At Birth 1y 2-12 mo

Centimeters 50 75 Age x 6 + 77

A P G A R 8 – 10: 4 – 7: 0 – 3:

FONTANELS Age 0-3 mo 3-6 mo 6-9 mo 9-12 mo Gain in 1st Year is ~ 25cm + 9 cm 3 cm per mo + 8 cm 2.67 per mo + 5 cm 1.6 cm per mo + 3 cm 1 cm per mo HEAD CIRCUMFERENCE (33-38 cms) Age At Birth < 4 mo 5-12 mo 1-2 yrs 3-5 yrs 6-20 yrs Inches 35 cm (13.8 in) + 2 in (1/2 inches / mo) + 2 in (1/4 inches / mo) + 1 inch + 1.5 in (1/2 inches / year) + 1.5 in (1/2 inches / year) Centimeters + 5.08cm (1.27cm / mo) + 5.08cm (0.635cm / mo) 2.54 cm + 3.81cm (1.27cm / mo) + 3.81cm (1.27cm / mo) TI = Appropriate size at birth: Closes at: Anterior Posterior 2 x 2 cm (anterior) = 18 months, or as early as 9-12 months = 6 – 8 weeks or 2 – 4 months

Normal Mild / Moderate Asphyxia Severe asphyxia GCS

THORACIC INDEX transverse chest diameter AP diameter Birth 1 year 6 years : 1.0 : 1.25 : 1.35

Function Eye Opening Verbal

Motor

Infants/Young 4- Spontaneous 3- To speech 2- To pain 1- None 5- Appropriate 4- Inconsolable 3- Irritable 2- Moans 1- None 6- Spontaneous 5- Localize pain 4- Withdraw 3- Flexion 2- Extension 1- None

Older Spontaneous To speech To pain None Oriented Confused Inappropriate Incomprehensible None Spontaneous Localize pain Withdraw Flexion Extension None

EXPANDED PROGRAM ON IMMUNIZATION VACCINE BCG-1 AGE Birth or 6 wks 6 wks 6 wks 6 wks 9 mos School entry Childbearing women DOSE 0.05mL (NB) 0.1mL (older) 0.5mL 2 drops 0.5mL 0.5mL 0.1mL 0.5mL # 1 ROUTE ID SITE RDeltoid Upper Outer thigh Mouth Anterolateral thigh Outer upper arm LDeltoid Deltoid INTERVAL BCG

ADVERSE REACTIONS FROM VACCINES 1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks 2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis 1. Fever, local soreness 2. Convulsions, encephalitis / encephalopathy, permanent brain damage Paralytic Polio Local soreness 1. Fever & mild rash 2. Convulsions, encephalitis / encephalopathy, SSPE, death
ACTIVE BCG DPT OPV Hep B Measles Hib MMR Tetanus Toxoid Varicella PASSIVE Diphtheria Tetanus Tetanus Ig Measles Ig Rabies (HRIg) Hep A Ig Hep B ig Rubella Ig

DPT OPV HEPA B MEASLES BCG-2 TetToxoid

3 3 3 1 1 3

IM PO IM SC ID IM

DPT OPV HEPA B MEASLES

4 wks 4 wks 4 wks

1 mo then 6-12 mos H.E.A.D.S.S.S. Home Environment ◦ With whom does the adolescent live? ◦ Any recent changes in the living situation? ◦ How are things among siblings? ◦ Are parents employed? ◦ Are there things in the family he/she wants to change? Employment and Education ◦ Currently at school? Favorite subjects? ◦ Patient performing academically?

H.E.A.D.S.S.S. Sexual activities ◦ Sexual orientation? ◦ GF/BF? Typical date? ◦ Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs? Suicide/Depression ◦ Ever sad/tearful/unmotivated/hopeless? ◦ Thought of hurting self/others? ◦ Suicide plans? Safety ◦ Use seatbelts/helmets? ◦ Enter into high risk situations? ◦ Member of frat/sorority/orgs? ◦ Firearm at home? F.R.I.C.H.M.O.N.D.

NUTRITION CAL 115 110 110 90-100 80-90 70-80 55-65 45-50 CHON 3.5 3.0 2.5 2.0 1.5 1.5 1.5 1.2

AGE 0-5 mo 8-11 mo 1-2 y 3-6 y 7-9 y 10-12 y 13-15 y 16-19 y TCR β TCR

WT. 3-6 7-9 10-12 14-18 22-24 28-32 36-44 48-55


◦ ◦ ◦

Have been truant / expelled from school? Problems with classmates/teachers? Currently employed? Future education/employment goals? What he/she does in spare time? Patient does for fun? Whom does patient spend spare time? Hobbies, interests, close friends?

= Wt at p50 x calories = CHON X ABW : calories X amount of intake (oz) : age in months + 2 : 2-3 hours 1:2 Bonna Nursoy Promil S-26 Similac SMA

Total Caloric Intake Gastric Capacity Gastric Emptying Time 1:1 Alacta Enfalac Lactogen Lactum Nan Nestogen Nutraminogen Pelargon Prosobee

◦ ◦ ◦ ◦ ◦ ◦ ◦

Fluids Respiration Infection Cardiac Hematologic Metabolic Output & Input [cc/kg/h] N: 1-2

Activities ◦ ◦ ◦ ◦ Drugs ◦ ◦ ◦

Used tobacco/alcohol/steroids? Illicit drugs? Frequency? Amount? Affected daily activities? Still using? Friends using/selling?

THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE
by Stephen R. Covey

Habit 1: Habit 2: Habit 3: Habit 4: Habit 5:

Be Proactive Begin with the end in mind Put First Things First Think Win-Win Seek first to understand and then to be understood Habit 6: Synergize Habit 7: Sharpen the saw

EXPECTED LA SALLIAN GRADUATE ATTRIBUTES (ELGA) 1. Competent & safe physicians 2. Ethical & socially responsible Doctors / practitioners 3. Reflective lifelong learners 4. Effective communicators 5. Efficient & innovative managers

DIARRHEA

TREATMENT PLAN A ACUTE DIARRHEA (at least 3x BM in 24 hrs) 4 Rules of Home Treatment

◦ ◦

Chronic Persistent

: >14 days, non-infectious causes : >14 days, infectious cause

ORS vol. after each loose stool 1 day <24 mo 2-10 y.o. >10 y.o. 5-100mL 100-200mL As much as wanted 500mL 1000mL 2000mL

For severe dehydration / WHO hydration (fluid: PLR 100cc/kg) Age <12 >12 Patient in SHOCK ◦ ◦ ◦ 20-30cc/kg IV fast drip but in infants 10cc/kg IV (repeat if not stable) If responsive & stable 75/kg x 4-6 hours 30mL/kg 1H 30 mins 75mL/kg 5H 2½H

TREATMENT PLAN C ETIOLOGY of AGE Treat severe dehydration QUICKLY! 4 Major Mechanisms fluid (as much as the child Bacteria Viruses 1. Give extra Aeromonas Start IV fluid immediately Astroviruses 1. will take) Poorly absorbed osmotically active substances in Bacillus cereus Caloviruses lumen Campylobacter jejunichild can drink, give Norovirus If the ORS by > Breastfeed frequently & longer at each feeding 2. Intestinal ion secretion (increased) or decreased Clostridium perfringens > if the child mouth while the IV drip is beingEnteric Adenovirus set up absorption is exclusively breastfed, give one or Clostridium difficile Rotavirus more of the following in addition to breastmilk Escherichia coli Cytomegalovirus Give 100mL/kg Lactated Ringer’s Outpouring ◦ ORS solution into the lumen of blood, Plesiomonas shigelbides Herpes simplex virus solution mucus Salmonella food based fluid (e.g. soup, rice, water) 4. Derangement of intestinal motility TREATMENT PLAN B Shigella clean water First give Then give Age Staphylococcus aureus 30mL/kg in: 70mL/kg in: Recommended usual amount of ORS over 4 Vibrioperiod 01 & 0139 hour cholerae How muchAGE to be givenfirst then diarrhea) fluid (vomiting in addition to the Infants Rotaviral 1 5 hours Vibrio parahaemolyticus hour* fluid intake? (<12mo) 2 yrs – Age up to: 4 mo – 4 mo 12 mo – 12 mo 5 yrs Yersinia enterocolitica 2 yrs Ingestion of rotavirus ► rotavirus in intestinal villi Children 10-11.9kg Wt: <6kg 6-9.9kg 2-19kg hours 30 min* 2½ Up to 2 years:►destruction of villi after each 50-100 mL (12mo-5yrs) 700-900 (mL) 200-400 400-700 900-1400 Parasites loose stool Balantidium coli (secretory diarrhea ▼absorption ▲ secretion) ► AGE ◦ mL Blastocyctis hominis 2 years or more: 140-200Use child’s age only when weight is not known once if radial pulse is very weak or not Repeat ◦ Approximate amount of ORS (mL) Cryptosporidium :- give frequent small sips from a cup detectable Giardia lamblia :- if the child vomits, wait (Skin Pinch Test) Assessment of dehydrationfor 10 min then CHILDS WT (kg) x 25 resume ◦ (+):- > 2 seconds if continue giving extra fluids until diarrhea reassess the child every 15-30 min. ◦ if the child wants more ORS than shown, give more Amoeba Metronidazole if dehydration is not improving, stops give frequent small sips from a cup no dehydration if skin tenting◦ goes back Ascariasis Al/mebendazol give IV ◦ if the child vomits, wait for 10 min then resume fluid more rapidly immediately e 2. Give Zinc supplements ◦ continue breastfeeding whenever the child wants ORS (~5mL/kg/hr) as soon as the child ◦ also give Cholera Tetracyline can drink [usually after 3-4 hours in infants; 1-2 Shigella TMP/SMX Up to 6 mo: 1 half tab per day for 10-14 days AFTER 4 HOURS hours in children] (Cotri) 6 months or more:reassess20mg ◦ 1 tab or the child & classify dehydration status Salmonella Chloramphenic OD x 10-14 daysselect the appropriate plan to continue treatment after 6 hrs (infant) & 3 hrs (child) ◦ reassess ◦ ol ◦ begin feeding the child while at the clinic 3. Continue feeding

1. 2. 3.

3.

ORS • Glucolyte 60 -: for acute DHN secondary to GE or other forms of diarrhea except CHOLERA. In burns, postsurgery replacement or maintenance, mild-salt loosing syndrome, heat cramps and heat exhaustion in adults. Cl: 50mmol/L Mg: 5mmol/L Citrate: 10 mmol/L Gluconate: 5mmol/L • Pedialyte 45 0r 90 -: prevention of DHN & to maintain normal fluidelectrolyte balance in mild to moderate dehydration. Glucose 45mEq Na: 20mEq K: 35mEq Citrate: 30mEq Dextrose: 20g Glucose 90mEq Na: 20mEq K: 80mEq Citrate: 30mEq Dextrose: 25g

IV-FLUID COMPOSITIONS (Commonly Used for Infants and Child):

ETIOLOGY OF PNEUMONIA Bacterial - Streptococcus pneumoniae - Group B streptococci (neonates) - Group A streptococci - Mycoplasma pnemoniae (adolescents) - Chlamydia trachomatis (infants) - Mixed anearobes (aspiration pneumonia) - Gram negative enteric (nosocomial pneumonia) Viral - Respiratory syncitial virus - Parainfluenza type 1-3 - Influenza types A, B - Adenovirus - Metapneumovirus Fungal - Histoplasma capsulatum - Cryptococcus neoformans contact) - Aspergillus sp. (immunosuppressed) - Coccidioides immitis - Blastomyces dermatitides - Pneumocystis carinii

ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)

Glucose: 100mmol/L Na: 60 mol/L K: 20 mmol/L

(Croup)

• Hydrite -: 2 tab in 200ml water or 10sachets in 1L water Glucose: 111mmol/L Na: 90 mmol/L K: 20 mmol/L

Pedialyte mild 30 -: to supplement fluid & electrolyte loss due to active play, prolonged exposure, hot and humid environment Glucose: 30mEq Na: 20mEq K: 30mEq Mg: 4mEq lactate: 20mEq Ca: 4mEq Energy: 20kcal/ 100ml

(bird, bat contact) (bird (immunosuppressed) Mucormycosis

Child Age 2months up to 5years

Young Infants < 2months old

Cl: 80mmol/L HCO3: 5mmol/L

Glucose: 11mml/L Na: 90 mmol/L K: 20 mmol/L

(immunosuppressed, HIV, steroids)

SMR GIRLS LUDAN’S METHOD (HYDRATION THERAPY) MILD DEHYDRATION 50 cc/kg 30 cc/kg D5 0.3% in 6-8 hours MODERATE DEHYRATION 100 cc/kg 60 cc/kg st 1 hr: ¼ Plain LR Next 5-7 hrs: ¾ D5 0.3% in 5-7 hours SEVERE DEHYDRATION 150 cc/kg 90 cc/kg st 1 hr: ⅓ Plain LR Next 5-7 hrs: ⅔ D5 0.3% in 5-7 hours
Stage 1 2 3 4 5 Pubic Hair Preadolescent Sparse, lightly pigmented, straight, medial border of labia Darker, beginning to curl, ▲amount Course, curly, abundant but amount < adult Adult, feminine triangle, spread to medial surface of thigh Breasts Preadolescent Breast & papilla elevated, as small mound, areola diameter increased Breast & areola enlarged, no contour separation Areola & papilla formed secondary mound Mature, nipple projects, areola part of general breast contour

< 15 kg, < 2 y/o > 15 kg, 2 y/o

HOLIDAY-SEGAR METHOD (MAINTENANCE) WEIGHT 0 - 10 kg 11- 20 kg > 20 kg NOTE: TOTAL FLUID REQUIREMENT 100 mL / kg 1000 + [ 50 for each kg in excess of 10 kg] 1500 + [ 20 for each kg in excess of 20 kg]

SMR BOYS
Stage 1 2 3 4 5 Pubic Hair None Scanty, long slightly pigmented Darker, starts to curl, small amount Resembles adult type but less in quantity, course, curly Adult distribution, spread to medial surface of thigh Penis Preadolescent Slightly enlargement Longer Larger, glans & breadth ▲ in size Adult size Testes Preadolescent Enlarged scrotum, pink texture altered Larger Larger, scrotum dark Adult size

Computed Value is in mL/day Ex. 25kg child Answer: 1500 + [100] = 1600cc/day

ATYPICAL PNEUMONIA DENGUE > extrpulmonary manifestations (man as reservior) -: MOT: mosquito bite -: low grade fever > patchy -: Vector: diffuse infiltrates Aedes aegypti -: poor response to Penicillin > negative sputum gram stain -: Factors affecting transmission: - breeding sites, high human population density, mobile viremic human beings Etiologic Agents Grouped by Age > Age incidence peaks at 4-6 yrs > Neonates (<1mo) > - GBS Incubation period: 4-6 days - E. coli > - other gram (-) bacilli Serotypes: --Streptococcus pneumoniae Type 2 – most common --Haemophilus influenza (Type B) Types 1& 3 - Type 4– least common but most severe > 1-3 months > * Febrile pneumonia changes: Main pathophysiologic a. increase in vascular permeability - RSV - Other respiratory viruses ▼ - extravasation of plasma Streptococcus pneumoniae - Haemophilus influenza (Type B) - hemoconcentration - 3rd spacing of fluids * Afebrile pneumonia b. abnormal hemostasis - Chlamydia trachomatis - - vasculopathy Mycoplasma homilis - - thrombocytopenia CMV - coagulopathy

Dengue Fever Syndrome (DFS) > 3-12 mo Biphasic fever (2-7 days) with 2 or more of the ff: - RSV - Other respiratory viruses 1. - Streptococcus pneumoniae headache 2. - Haemophilus influenzae (Type B) myalgia or arthralgia 3. - C. trachomatis retroorbital pain 4. - M. pneumoniae hemorrhagic manifestations - Group A Streptococcustorniquet test] [petechiae, purpura, (+) 5. leukopenia > 2-5 yrs - RSV Dengue Hemorrhagic Fever (DHF) - Other respiratory viruses 1. - Streptococcus pneumoniae (2-7 days) fever, persistently high grade 2. - Haemophilus influenzae (Type B) hemorrhagic manifestations - -C. trachomatis (+) torniquet test - -M. pneumoniae petechiae, ecchymoses, purpura - -Group A Streptococcus GIT, puncture sites bleeding from mucusa, - -Staph aureus melena, hematemesis 3. Thrombocytopenia (< 100,000/mm3) 4. 2-5 yrs > Hemoconcentration - Streptococcus pneumoniae>20% from baseline hematocrit >40% or rise of - Haemophilus influenzae (Type B) following a drop in >20% Hct (from baseline) - C. volume replacement trachomatis - M. pneumoniae leakage signs of plasma - Group Aeffusion, ascites, hypoproteinemia] [pleural Streptococcus - Staph aureus

Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse 2. narrow pulse pressure (<20mmHg) 3. hypotension for age 4. cold, clammy skin & irritability / restlessness DANGER SIGNS OF DHF

DENGUE PATHOPHYSIOLOGY

1. abdominal pain (intense & sustained) 2. persistent vomiting 3. abrupt change from fever to hypothermia with sweating 4. restlessness or somnolence Grading of Dengue Hemorrhagic Fever

MANAGEMENT OF DENGUE A. Vital Signs and Laboratory Monitoring Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)

MANAGEMENT OF HEMORRHAGE

Torniquet Test: SBP + DBP = mean BP for 5 mins. ACUTE GLOMERULONEPHRITIS 2 Complications of AGN sq. inch on antecubital fossa if ≥20 petechial rash per - CHF (+) test2° to fluid overload - HPN encephalopathy - ARF due to ê GFR Herman’s Rash: - usually appears after fever lysed - initially appears on the lower extremities STAGES of AGN - not a common finding among dengue patients - Oliguric phase [7-10days] “an island of white in an ocean of red” – complications sets in - Diuretic phase [7-10days] – recovery starts - Convalescent phase [7-10days] – patients are B. Secondary Prevention usually sent home Recommended Guidelines for Transfusion: Prognosis Transfuse: - Gross hematuria 2-3 weeks - PC < 100,000 with signs of bleeding 3-6 weeks - Proteinuria - PC < 20,000 even if asymptomatic - ▼C3 8-12 weeks - use FFP if without overt bleeding - microscopic hematuria 6-12 mo or - FWB in cases with overt bleeding or 1-2 years signs of hypovolemia - HPN 4-6 weeks C. Duration of Chemoprophylaxis > if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate due to Na+ retention > Hyperkalemia may be seen > Ca++ decreases in PSAGN st 3-7cc/kg/hr titer > ▲ in ASO depending on the Hct (1 no.) level (D5LR) - normal within 2 weeks 10-20cc/kg fast2drip PLR - hypotension, narrow pulse - peaks after weeks pressure fair pulse - more pronounced in pharyngeal infection than in cutaneous Leukopenia in dengue: probable etiology is Pseudomonas

URINARY TRACT FEVER RHEUMATIC INFECTION JONES CRITERIA: Suggestive UTI: A. Major Manifestations - Pyuria: WBC ≥ 5/HPF or 10mm3 - Absence of pyuria doesn’t rule out UTI (50-60%) - Carditis - Pyuria can be present w/o UTI - Polyarthritis (70%) - Chorea (15-20%) Presumptive Marginatum - Erythema UTI: (3%) - (-)Subcutaneous Nodules - urine culture (1%) - lower colony counts may be due to: B.*Minor Manifestations overhydration * recent bladder emptying - Arthralgia * previous antibiotic intake - Fever - Laboratory Findings of: ProvenAcute Phase Reactants (ESR / CRP) ▲ or Confirmed UTI: - (+) urine culture ≥ 100,000 cfu/mL urine of a single Prolonged PR interval organism C. PLUS Supportingin culture may Antecedent - multiple organisms Evidence of indicate a contaminated sample Group-A Strep Infection - (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test

TREATMENT OF RHEUMATIC FEVER A. Antibiotic Therapy - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin *** NOTE: Sumapen = Oral Penicillin!

B. Anti-Inflammatory Therapy 1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks 2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days

PREVENTON A. Primary Prevention - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin

KAWASAKI DISEASE TYPES OF SEIZURES CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI A. Partial Seizures (Focal / Local) (ALL SHOULD BE PRESENT) – Simple Partial A) HIGH Grade Partial (>38.5 Rectally) PRESENT Complex Fever (Partial Seizure + for AT LEAST 5-days without other Explanation Impaired Consciousness) “High Grade Fever of at least 5 days” Partial Seizures evolving kind of Antibiotic! DOES NOT Respond to any to Tonic-Clonic Convulsion B) Presence of 4 of the 5 Criteria 1. Bilateral CONGESTION of the Ocular Conjunctiva B. Generalized Seizures (seen in 94%) Absence 2. Changes of the Lips and (Petit Cavity (At least ONE) Oral mal) – Myoclonic 3. Changes of the Extremities (At least ONE) – Clonic 4. Polymorphous Exanthem (92%) – Tonic 5. Cervical Adenopathy = Non-Suppurative Cervical – Tonic-Clonic Adenopathy (should be >1.5cm) in 42%) – Atonic HARADA Criteria - used to determine whether IVIg should be given SIMPLE FEBRILE SEIZURE - assessed within 9 days from onset of illness vs. 1. WBC > 12,000 COMPLEX 2. PC <350,000 FEBRILE SEIZURE 3. CRP > 3+ Febrile Seizure: 4. Hct <35% “A seizure in association with a febrile illness in the absence of Albumin <3.5 g/dL or acute electrolyte a CNS infection 6. Age in children imbalance 12 months older than 1 month of age 7. prior afebrile withoutGender: male seizures” CLASSIFICATION BY CAUSE TREATMENT A. Acute Symptomatic Currently Recommended Protocol: (shortly after an acute insult) A. – Infection IV-Immunoglobulin – Hypoglycemia, low sodium, low calcium –2g/kg Regimen Infusion EQUALLY Effective in Head trauma – Toxic ingestion Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation B. Remote Symptomatic by days of as measured Fever, ESR, CRP,brain abnormality or insult Albumin – Pre-existing Platelet Count, Hgb, and – Brain injury (head trauma, low oxygen) NOTE: – Meningitis There is a TIME FRAME of 10 days – Stroke – Tumor B. – Developmental brain abnormality Aspirin C. HIGH Dose ASA (80-100mg/kg/day divided q 6h) Idiopathic should history ofInitially in Conjunction with IV-IG – No be given preceding insult – Likely “genetic” component THEN Reduced to Low Dose Aspirin (3-5mg/kg/day) AND Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease) SIMPLE SEIZURES FEBRILE SEIZURE A. Criteria for an SFS > Seizures: sudden event < 15 minutes – caused by abrupt, – uncontrolled, hypersynchronous Generalized-tonic-clonic – discharges of Fever > 100.4 rectal to neurons 101 F (38 to 38.4 C) > Epilepsy: tendency for recurrent seizures24 hours – No recurrence in that are – unprovoked by an immediate cause No post-ictal neuro abnormalities (e.g. Todd’s paresis) > Status epilepticus: – >30min or back-to-back to Most common 6 months 5 years w/o return to baseline – Normal development > Etiology: – No CNS infection or prior - V ascular afebrile seizures : AVM, stroke, hemorrhage - I nfections : meningitis, encephalitis - T Risk Factors: B. raumatic - A utoimmune : SLE, vasculitis, ADEM nd Febrile seizure in 1st - M etabolic : electrolyte imbalance/ 2 degree : - I diopathic relative “idiopathic epilepsy” Neonatal nursery stay of -N– eoplastic : space occupying lesion >30 days : - S tructural cortical malformation, – Developmental delay prior stroke Height disorder - S–yndrome : genetic of temperature

– – –

5.

• •

IVIg is given if ≥ 4 of 7 are fulfilled If < 4 with continuing acute symptoms, risk score must be reassessed daily

C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy) – Developmental delay – Complex FS (possibly > 1 complex feature) – 5% > 30 mins => _ of all childhood status – Family History of Epilepsy – Duration of fever

BRONCHIAL ASTHMA (GINA GUIDELINES) Controlled Day symptoms Limitation of activities Nocturnal Sx (awakening) Need for reliever Lung function Exacerbation none none none < 2x per wk normal none Partly Controlled > 2x per wk any any > 2x per wk < 80% > 1x per yr 1x / week 3 or more symptoms of Partly Controlled Asthma in any week Uncontrolled

Clinical Features: TUBERCULOSIS A. Pulmonary TB RESPIRATORY DISTRESS SYNDROME (Hyaline Membrane Disease) o Male, preterm, low BW, maternal DM, & perinatal asphyxia o Corticosteroids: • most successful method to induce fetal lung maturation • Administered 24-48 hours before delivery decrease incidence of RDS • Most effective before 34 weeks AOG o Microscopically: diffuse atelectasis, eosinophilic membrane Pathophysiology: 1. secretion 2. 3. 4. 5. 6. 8. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance Hypoxemia and systemic hypoperfusion Respiratory and metabolic acidosis Pulmonary vasoconstriction Impaired endothelial &epithelial integrity Proteinous exudates RDS Impaired/delayed surfactant synthesis & 1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting

– fully susceptible M. tuberculosis, – no history of previous anti-TB drugs
– low local persistence of primary resistance to Isoniazid (H) ☤ then 4HR OD or 3x/wk DOT 2HRZ OD

2. 3.

Pallor – from anemia, peripheral vasoconstriction Onset – within 6 hours of life Peak severity – 2-3 days Recovery – 72 hours

– Microbial susceptibility unknown or initial drug
resistance suspected (e.g. cavitary) – previous anti-TB use – close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H. –

Retractions: o Due to (-) intrapleural pressure produced by interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall Nasal flaring: o Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance Grunting: o Expiration through partially closed vocal cords


B.

2HRZ + E/S OD, then 4 HR + E/S OD or 3x/week DOT


Extrapulmonary TB – Same in PTB – For severe life threatening disease (e.g. miliary, meningitis, bone, etc) ☤ 2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT

7.

Initial expiration: glottis closedà lungs w/ gasà inc. transpulmo P w/o airflow Last part of expiration: gas expelled against partially closed cords

Cyanosis: Central – tongue & mnucosa (imp. Indicator of impaired gas exchange); depends on

UMBILICAL CATHERIZATION NEWBORN RESUSCITATION Indications • Vascular access (UV) • Blood Pressure (UA) and blood gas monitoring in critically ill infants Complications • Infection • Bleeding • Hemorrhage • Perforation of vessel • Thrombosis w/ distal embolization Cathether length • Standardize Graph


• •

AIRWAY: Positioning Suctioning

open & clear


• •

•  •

Endotracheal intubation (if necessary) BREATHING is spontaneous or assisted Tactile stimulation (drying, rubbing) Positive-pressure ventilation CIRCULATION of oxygenated blood is

Perpedicular line from the tip of the shoulder to the umbilicus Measure length from Xiphoid to umbilicus and add 0.5 to 1cm. Birth weight regression formula


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Ischemia or infarction of lower extremities, bowel or kidney Arrhythmia Air embolus

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Low line High line

: UA catheter in cm = BW + 7 : UA catheter = [3xBW] + 9 = [0.5xhigh line] + 1

UV catheter length

adequate • Chest compressions • Medication and volume expansion

RESUSCITAION MEDICATIONS Atropine Bicarbonate Calcium Calcium chloride Calcium gluconate Dextrose Epinephrine 0.02 ml/k IM, IV, ET 1-2 meq/k 10 mg elem Ca/k slow IV 0.33/k (27 mg Ca/cc) 1 cc/k (9 mg Ca/cc) 1g/k = 2 cc/k D50 4 cc/k D25 0.01 cc/k IV, ET

Cautions • Never for: – Omphalitis – Peritonitis • Contraindicated in – NEC – Intestinal hypoperfusion Line Placement • Arterial line • Low line – Tip lie above the bifurcation between L3 & L5 • High line – Tip is above the diaphram between T6 & T9

Procedure • Determine the length of the catheter • Restrain infant and prep the area using sterile technique • Flush catheter with sterile saline solution • Place umbilical tape around the cord. Cut cord about 1.5-2cm from the skin. • Identify the blood vessels. (1thin=vein, 2thick=artery) • Grasp the catheter 1cm from the tip. Insert into the vein, aiming toward the feet. • Secure the catheter • Observe for possible complications

BILIRUBIN PRETERM: 0-1 hr 1-2 d 3-5 d TERM 0-1 hr 1-2 d 3-5 d 1 mo mg/dl 2-6 6-7 4-12 <1 mmol/L 34-100 100-120 70-200 <17 mg/dl 1-6 6-8 10-12 mmol/L 17-100 100-140 170-200

KRAMERS CLASSIFICATION OF JAUNDICE ZONE I II III IV V JAUNDICE Head & neck Upper trunk to umbilicus Lower trunk to thigh Arms, legs, below Hands & feet SERUM BILIRUBIN 6-8 9-12 12-16 15 15

MKD COMPUTATION LUMBAR PUNCTURE • the technique of using a needle to withdraw cerebrospinal fluid (CSF) from the spinal canal. • To diagnose other medical conditions such as: – viral and bacterial meningitis – syphilis, a sexually transmitted disease – bleeding around the brain and spinal cord – multiple sclerosis, (affects the myelin coating of the nerve fibers of the brain and spinal cord) – Guillain-Barré syndrome, (inflammation of the nerves) Wt x mkd x preparation [mg/mL] = mL per dose e.g. 12kg x 10mg x 5ml = 5mL per dose 120mg

SPINE Procedure • spinal cord stops near L2 Apply local anesthetic cream (ideally) • lower lumbar spine (usually between L3-L4 or • L4–5) is preferable Position the patient • Prepare the skin using sterile techniques • Anesthetize the area with lidocane CSF • clear, watery liquid that protects the central Puncturesystem from injury nervous the skin in the midline just caudal to the • spinus process, angle cephalad toward the cushions the brain from the surrounding bone. umbilicus using a g23 needle • It contains: • Collect the CSF for analysis glucose (sugar) CSF Analysis protein 1. Gram stain, culture and sensitivity 2. – white blood cells count Cell count, differential CLASSIFICATION BASED ON SEVERITY Rate : 500ml/day or sugar, protein Chemistries – 0.35ml/min 4. Special studies Range : 0.3-04 ml/min PERSISTENT INTERMITTENT MILD MODERATE After care : 50ml (infants) Volume • Cover the puncture site with a sterile bandage, Affects daily Affects daily 150ml (adults) apply pressure packing. Exacerbation Brief activity & activity & • Patients must remain lying down for 4-6 sleep hours sleep Indication •Day-time Sxs hrs NPO for 4 <1x/wk >1x/wk and daily • to diagnose some malignancies (brain cancer Nightime Sxs <2x/mo >2x/mo >1x/wk leukemia) PEFR >80% >80% 60 - <80% to VAR psychiatric PEFR assess patients with certain 20 - 30% <20% >30% symptoms and conditions. FEV1 >80% >80% 60 - <80%

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Complication • Local pain • Infection • Bleeding • Spinal fluid leak • Hematoma (spinal subdural hematoma • Spinal headache • Acquired epidermal spinal cord tumor Caution & Contraindications • Increased ICP • Bleeding diasthesis • Traumatic Tap • Overlying skin infection • Unstable patient SEVERE Limits daily activity & sleep continuous frequent <60% >30% <60%

* If per day, divide total (mL) by the # of divided doses Empirical dose  6 months ¼ tsp TID QID Dose x preparation x frequency½= mkd  6 mos – 2 yrs tsp weight tsp  2-6 1  6-9 1 ½ tsp  9-12 2 tsp

Paracetamol Drops

= Wt: move 1

decimal Age 1 2 CLINICAL FEATURES 3 4 5SEVERE MILD MODERATE 6 - talking - INF: softer, drop - at rest 1 shorter, cry,teaspoonful - INF: stops 1 - walking difficulty 1 tablespoonful feeding - can lie down feeding 1 wineglassful - hunched - prefers 1 glassful forward sitting 1 grain sentences phrases 1 pint words may be usually 1 quart usually agitated agitated 1 ounce agitated often >30 1 Kg ▲ ▲ mins none (+) (+) point to the left Wt 10 kg 12 14 16 18 RESPIRATORY ARREST 20 = 1/20 mL = 5 mL = 15 mLImminent = 60 mL = 2 ounces = 250 mL = 8 ounces = 60 mg = 500 mL drowsy / = 1000 mL = 30 mLconfused = 2.2 lbs bradypnea (+) thoracoabd movement

• 3. • •

Breathless

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Talks in Alertness RR Accessory muscles & retractions

for injecting chemotherapy directly into the CSF