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TREATMENT GUIDELINES

2010

CHILD HEALTH DIRECTORATE


KOMFO ANOKYE TEACHING HOSPITAL
KUMASI - GHANA

Child Health Directorate TREATMENT GUIDELINES

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TABLE OF CONTENTS
TABLE OF CONTENTS ........................................................................................................................................................ I
FOREWORD ..................................................................................................................................................................... V
PREFACE TO HANDBOOK ON DEPARTMENTAL PROTOCOLS ........................................................................................... VI
PROTOCOL REVIEW COMMITTEE ...................................................................................................................................VII
LIST OF CONTRIBUTORS ................................................................................................................................................. VIII
1.0 PAEDIATRIC RESUSCITATION ............................................................................................................................ 1
1.1.0 CARDIOPULMONARY RESUSCITATION ................................................................................................................... 1
SUMMARY OF ABCD MANEUVERS .............................................................................................................................. 3
1.2.0 AIRWAY AND BREATHING MANAGEMENT PROTOCOL ........................................................................................... 4
1.3.0 ASYSTOLE ............................................................................................................................................................... 5
1.3.1 FIRST STEPS ....................................................................................................................................................... 5
1.3.2 PULSELESS ELECTRICAL ACTIVITY Not Shockable  Remember PEA ........................................................... 5
1.3.3 ASYSTOLE  Not shockable  Remember DEAD ....................................................................................... 5
1.2.0 ANAPHYLAXIS.......................................................................................................................................................... 7
ANAPHYLAXIS TREATMENT ALGORITHM .................................................................................................................... 9
2.0 NEUROLOGICAL DISORDERS............................................................................................................................ 11
2.1.0 CONVULSIONS / SEIZURE DISORDERS ................................................................................................................... 11
2.1.1 DEFINITIONS AND CLASSIFICATION .................................................................................................................. 11
2.1.2 GENERAL AETIOLOGY OF CONVULSIVE DISORDERS ........................................................................................ 12
2.1.3 DIAGNOSIS........................................................................................................................................................ 12
2.1.4 ACUTE MANAGEMENT OF SEIZURES / CONVULSIONS ..................................................................................... 13
ACUTE MANAGEMENT .............................................................................................................................................. 15
2.1.5 OTHER INVESTIGATIONS TO SUPPORT DIAGNOSIS OF EPILEPSY ..................................................................... 16
2.1.6 DIFFERENTIAL DIAGNOSIS ................................................................................................................................ 18
2.1.7 ANTIEPILEPTIC DRUG (AED) THERAPY .............................................................................................................. 19
2.1.8 SURGERY FOR EPILEPSY .................................................................................................................................... 22
2.1.9 PSYCHOLOGICAL MANAGEMENT ..................................................................................................................... 22
2.1.10 OTHER PROBLEMS ASSOCIATED WITH EPILEPSY THAT NEED THE PHYSICIANS ATTENTION ......................... 22
2.1.11 INTEGRATED EPILEPSY SERVICE (MULTI-DISCIPLINARY) ................................................................................ 23
2.1.12 OUTCOME OF TREATMENT ............................................................................................................................ 23
2.2.1 ACUTE FLACCID PARALYSIS ................................................................................................................................... 24
2.2.2 MANAGEMENT OF POLIOMYELITIS ....................................................................................................................... 25
2.2.3 MANAGEMENT OF GUILLAIN-BARRE SYNDROME................................................................................................. 25
2.3.0 ACUTE ENCEPHALOPATHY / NON TRAUMATIC COMA .......................................................................................... 26
2.3.1 SOME COMMONLY USED COMA SCALES .............................................................................................................. 28
3.0 CARDIAC DISORDERS ...................................................................................................................................... 30
3.1.0 ACUTE HYPERTENSION ......................................................................................................................................... 30
3.2.0 HEART FAILURE ..................................................................................................................................................... 32
3.3.0 INFECTIVE ENDOCARDITIS (IE) .............................................................................................................................. 34
3.4.0 RHEUMATIC HEART DISEASE ................................................................................................................................. 36
3.5.0 TETRALOGY OF FALLOT (TOF) AND HYPERCYANOTIC (TET) SPELL ......................................................................... 38
4.0 HAEMATOLOGICAL DISORDERS ....................................................................................................................... 39
4.1.0 SICKLE CELL DISEASE ............................................................................................................................................. 39
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4.1.1 INFECTION (MALARIA/SEPSIS/PNEUMONIA/OSTEOMYELITIS/UTIS ETC) ........................................................ 39


4.1.2 HYPERHEMOLYTIC CRISIS ................................................................................................................................. 40
4.1.3 SPLENIC SEQUESTRATION (MASSIVE RBCS + PLASMA SEQUESTRATION IN SPLEEN) ....................................... 40
4.1.4 APLASTIC CRISIS (CESSATION OF ERYTHROPOIESIS)......................................................................................... 40
4.1.5 VASO-OCCLUSIVE CRISIS ................................................................................................................................... 41
4.1.5.1 PRIAPISM .............................................................................................................................................................................. 42
4.1.5.2 ACUTE CHEST SYNDROME (PNEUMONIA/INFARCT) ......................................................................................................... 42
4.1.5.3 CVA ........................................................................................................................................................................................ 42

4.1.6 INDICATIONS FOR BLOOD TRANSFUSION: ....................................................................................................... 42


4.1.7 CHRONIC COMPLICATIONS ............................................................................................................................... 42
4.2.0 ANAEMIA TRANSFUSION ALGORITHM.................................................................................................................. 44
5.0 INFECTIOUS DISEASES ..................................................................................................................................... 45
5.1.0 MENINGITIS .......................................................................................................................................................... 45
5.2.0 SEVERE MALARIA .................................................................................................................................................. 48
5.2.1 CEREBRAL MALARIA ......................................................................................................................................... 48
5.2.2 MALARIA TREATMENT SUMMARY IN MALARIA ENDEMIC REGION ................................................................. 50
5.3.0 TETANUS ............................................................................................................................................................... 51
6.0 MALNUTRITION.............................................................................................................................................. 53
6.1.0 DEFINITION AND GENERAL GUIDELINES .......................................................................................................................... 53
CLASSIFICATION OF MALNUTRITION .............................................................................................................................................. 53
CLINICAL MANAGEMENT ................................................................................................................................................................. 53

6.1.1 TREATMENT OF SPECIFIC PROBLEMS OF THE SEVERELY MALNOURISHED ........................................................... 54


6.1.2 ROUTINE TREATMENT FOR THE MALNOURISHED ................................................................................................ 55
6.1.3 IMPORTANT THINGS NOT TO DO .......................................................................................................................... 55
6.1.4 SUMMARY OF WHO RECOMMENDATION FOR DIAGNOSIS AND MANAGEMENT OF SEREVE ACUTE
MALNUTRITION (SAM) IN CHILDREN ............................................................................................................................. 56
6.1.5 GUIDANCE TABLE TO IDENTIFY THE TARGET WEIGHT FOR DISCHARGE ................................................................ 57
7.0 NEONATAL DISORDERS ................................................................................................................................... 58
7.1.0 INTRODUCTION..................................................................................................................................................... 58
7.1.1 NEONATAL RESUSCITATION .................................................................................................................................. 58
RISK FACTORS ASSOCIATED WITH THE NEED FOR RESUSCITATION .......................................................................... 58
A B Cs of RESUSCITATION ......................................................................................................................................... 59
RESUSCITATION ALGORITHM .................................................................................................................................... 60
BAG-AND-MASK VENTILATION.................................................................................................................................. 61
CHEST COMPRESSIONS .............................................................................................................................................. 62
ENDOTRACHEAL INTUBATION................................................................................................................................... 63
7.2.0 BIRTH ASPHYXIA.................................................................................................................................................... 66
7.2.1 CLINICAL STAGES OF BIRTH ASPHYXIA (Perinatal Hypoxic Ischemic Encephalopathy) .................................... 68
7.3.0 NEONATAL SEIZURES: ........................................................................................................................................... 69
7.4.0 ANAEMIA IN THE NEWBORN ................................................................................................................................. 70
7.4.1 COMMON CAUSES OF ANAEMIA IN THE NEWBORN ....................................................................................... 70
7.4.2 CLINICAL FEATURES OF ANAEMIA IN THE NEWBORN ...................................................................................... 71
7.4.3 MANAGEMENT ................................................................................................................................................. 72
7.5.0 GUIDELINES FOR THE MANAGEMENT OF RESPIRATORY DIFFCULTY IN THE NEWBORN ....................................... 74
7.6.0 FEEDING PROTOCOL FOR BABIES ADMITTED TO THE MOTHER BABY UNIT, ......................................................... 75
7.7.0 GUIDELINES FOR THE MANAGEMENT OF NEONATAL JAUNDICE .......................................................................... 78
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7.7.1 PREPARATION FOR AN EXCHANGE BLOOD TRANSFUSION. ............................................................................. 78


7.7.2 PERFORMING THE EXCHANGE BLOOD TRANSFUSION (EBT) ............................................................................ 79
7.8.0 GUIDELINES TO THE MANAGEMENT OF THE HIV EXPOSED BABY ......................................................................... 80
7.9.0 MANAGEMENT OF COMMON BIRTH INJURIES ..................................................................................................... 81
7.9.1 CEPHALHAEMATOMA ...................................................................................................................................... 81
7.9.2 SUBGALEAL/SUBAPONEUROTIC HAEMATOMA ............................................................................................... 81
7.9.3 FRACTURED FEMUR ......................................................................................................................................... 81
7.9.4 FRACTURED HUMERUS .................................................................................................................................... 82
7.10.0 MANAGEMENT OF NEONATAL TETANUS (NNT) ................................................................................................. 83
7.10.1 AIMS OF MANAGEMENT ................................................................................................................................ 83
7.10.2 SPECIFIC STEPS TO TAKE ................................................................................................................................. 83
7.11.0 KANGAROO MOTHER CARE (KMC) ...................................................................................................................... 84
7.12.0 ANTIBIOTIC PROTOCOL FOR BABIES ADMITTED TO MBU ................................................................................... 85
8.0 FLUID & METABOLIC DISORDERS ..................................................................................................................... 86
8.1.0 DIABETIC HYPERGLYCEMIC CRISIS/COMA............................................................................................................. 86
9.0 ONCOLOGICAL DISORDERS ............................................................................................................................. 88
9.1.0 METABOLIC AND ONCOLOGIC EMERGENCIES ...................................................................................................... 88
9.1.1 TUMOUR LYSIS SYNDROME .................................................................................................................................. 88
9.1.2 FEBRILE NEUTROPENIA ......................................................................................................................................... 89
9.2.0 BASIC INVESTIGATIONS FOR ALL ONCOLOGY PATIENTS ....................................................................................... 90
9.3.0 RETINOBLASTOMA................................................................................................................................................ 91
9.4.0 RHABDOMYOSARCOMA ....................................................................................................................................... 92
9.5.0 BURKITTS LYMPHOMA ......................................................................................................................................... 93
9.6.0 HODGKINS LYMPHOMA ....................................................................................................................................... 95
9.6.1 TREATMENT PATHWAY IN STAGE II +III HODGKINS DISEASE................................................................................ 96
9.7.0 WILMS TUMOUR .................................................................................................................................................. 97
9.8.0 PAEDIATRIC ACUTE LYMPHOBLASTIC LEUKAEMIA (ALL) ....................................................................................... 98
9.8.1 PRE-TREATMENT PHASE ................................................................................................................................... 98
9.8.2 REGIMEN A INDUCTION ................................................................................................................................... 98
9.8.3 REGIMEN B INDUCTION ................................................................................................................................... 99
9.8.4 MAINTENANCE ................................................................................................................................................. 99
9.9.0 SOME COMMON DRUGS USED IN PAEDIATRIC ONCOLOGY PATIENTS ............................................................... 104
10.0 PAEDIATRIC EMERGENCIES ......................................................................................................................... 105
10.1.0 HYPOGLYCAEMIA .............................................................................................................................................. 105
10.2.0 FLUID THERAPY ................................................................................................................................................. 107
10.2.1 SHOCK ............................................................................................................................................................... 107
10.2.2 NORMAL MAINTENNANCE FLUIDS ................................................................................................................... 109
10.2.3 DIARRHEA AND DEHYDRATION ......................................................................................................................... 111
10.2.4 DIARRHOEA / DEHYDRATION (EXCLUDING SEVERE MALNUTRITION) ALGORTHM ........................................... 113
11.0 RENAL DISORDERS ...................................................................................................................................... 114
11.1.0 GENERAL GUIDE FOR ALL RENAL CASES ............................................................................................................ 114
11.2.0 DIETARY ADVICE FOR RENAL CASE .................................................................................................................... 115
11.3.0 NEPHRITIC SYNDROME (ACUTE GLOMERULONEPHRITIS) ................................................................................ 116
11.3.1 CLINICAL DEFINITION/CRITERIA ................................................................................................................... 116
11.3.2 MANAGEMENT GUIDELINES FOR NEPHRITIC SYNDROME (AGN) ................................................................ 116
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11.3.3 COMPLICATIONS & THEIR MANAGEMENT ................................................................................................... 117


11.4.0 NEPHROTIC SYNDROME.................................................................................................................................... 119
11.4.1 CLINICAL DEFINITION/CRITERIA FOR NEPHROTIC SYNDROME: ................................................................... 119
11.4.2 MANAGEMENT GUIDELINES FOR NEPHROTIC SYNDROME.......................................................................... 119
11.4.3 SECONDARY CAUSES OF NEPHROTIC SYNDROME ........................................................................................ 123
11.4.4 COMPLICATIONS OF NEPHROTIC SYNDROME & THEIR MANAGEMENT ...................................................... 124
11.5.0 URINARY TRACT INFECTION .............................................................................................................................. 126
11.6.0 ACUTE RENAL FAILURE ...................................................................................................................................... 128
11.7.0 CHRONIC RENAL FAILURE/CHRONIC KIDNEY DISEASE ...................................................................................... 132
12.0 RESPIRATORY DISORDERS ........................................................................................................................... 134
12.1.0 INTRODUCTION ................................................................................................................................................ 134
12.2.0 RESPIRATORY FAILURE ...................................................................................................................................... 135
12.3.0 CROUP .............................................................................................................................................................. 136
12.4.0 ASTHMA ............................................................................................................................................................ 139
12.5.0 APPROACH TO PNEUMONIAS ........................................................................................................................... 144
12.6.0 ATYPICAL PNEUMONIAS ................................................................................................................................... 146
12.7.0 PAEDIATRIC PULMONARY TUBERCULOSIS ........................................................................................................ 147
13.0 MISCELLANEOUS DISORDERS ...................................................................................................................... 149
13.1.0 SNAKE BITES ...................................................................................................................................................... 149
13.1.1 RECOGNITION OF VENOMOUS SNAKES ....................................................................................................... 149
13.1.2 CLINICAL FEATURES ...................................................................................................................................... 149
13.1.3 MANAGEMENT ............................................................................................................................................. 150
13.1.4 INDICATION FOR ANTIVENOM ..................................................................................................................... 150
13.1.5 ADMINISTRATION OF ANTIVENOM .............................................................................................................. 151
13.2.0 POISONING IN CHILDREN .................................................................................................................................. 152
13.3.0 SPECIFIC POISONING ......................................................................................................................................... 155
13.3.1 HYDROCARBONS .......................................................................................................................................... 155
13.3.2 CAUSTIC INGESTIONS ................................................................................................................................... 156
13.3.3 IRON POISONING .......................................................................................................................................... 157
13.3.4 PESTICIDES.................................................................................................................................................... 158
14.0 APPENDIX .................................................................................................................................................. 159
DRUGS IV/IO INFUSIONS TABLE ................................................................................................................................... 159
DRUG COMPATIBILITY TABLE ....................................................................................................................................... 160
DIGOXIN DIGITALIZATION AND MAINTENANCE DOSE TABLE ...................................................................................... 160
USEFUL FORMULAES ................................................................................................................................................... 161
RESPIRATORY AND HEART RATE REFERENCE FOR AGE ................................................................................................ 162
ESTIMATING BODY SURFACE AREA .............................................................................................................................. 162
WHO WEIGHT-FOR-LENGTH REFERENCE TABLE (45 -86CM) ....................................................................................... 163
WHO WEIGHT-FOR-LENGTH REFERENCE TABLE (87 -120CM) ..................................................................................... 164

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FOREWORD
Over a decade ago the first treatment protocol for the department was developed.
With the changing world and new advances in medicine, our energetic, Residents and Specialists under the
current Head of Department, Dr Addo-Yobo, have upgraded the previous one.
It does not replace the textbook but inspires the user and introduces to the Doctor and patient simple
practical and effective treatment within the subregion.
Definitely the time spent on this is worth the effort and will surely bring smiles to the faces of patients.

Prof. Ben Baffoe Bonnie


MD, FAFpaed, FWACPpaed, FGCP
Consultant Paediatrician
Second Head of Department, Child Health.

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PREFACE TO HANDBOOK ON DEPARTMENTAL PROTOCOLS


Established in 1975, the Department of Child Health, Komfo Anokye Teaching Hospital/School of Medical
Sciences, KNUST has seen significant developments from a clinical staff of less than 10 to the current state
as a centre for postgraduate training with of over 60 doctors, about 70% of whom are house officers and
residents. Certainly the number of clients and scope of services provided have also increased thus making it
necessary to develop subspecialty in the context of our practice.
From a twin general paediatric ward with a nursery in the 1980s the department now has 5 subunits based
on subspecialty. These are, Mother Baby Unit (MBU), Paediatric Emergency Unit (PEU), and three wards for
Cardiovascular/Respiratory, Haematology/Oncology and Infectious diseases (HIV)/Malnutrition/Renal
disorders respectively. All wards in addition take on patients with other miscellaneous disorders.
The first manual on paediatric protocols was written under the headship of the late Professor A.P. AsafoAgyei, the first Head of Department in the late 1980s as a pocket book. Since then, various departmental
protocols have been developed in specific areas on different wards at different times.
This current manual/handbook of paediatric treatment guidelines is an update of all previous forms and
versions from various wards and has been organized in accordance with functional structure of the
department as a quick treatment guide for House officers, Residents and other doctors, for the
management of a number of neonatal and general paediatric disorders as well as emergencies, as are
commonly seen. It is the joint effort of specialists and consultants from our various subunits.
It is hoped that this manual would continue to be useful to medical officers, residents as they leave our
teaching hospital and other clinical child health care practitioners outside the teaching hospital would also
find it helpful in the management of their patients.
The Department is especially grateful to members of the protocol review committee for compiling and
organizing the manual. It is our hope that the content would be updated yearly in accordance with current
paediatric practice.

E.O.D ADDO-YOBO Bsc, MB CHB, DTCH, MSc, MWACP, MD, FGCP


HEAD OF DEPARTMENT
2010

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PROTOCOL REVIEW COMMITTEE


Dr. Justice Sylverken (Chairman)
Dr. E.O.D Addo-Yobo
Dr. Charles K.A. Poku
Dr. Alex Osei-Akoto
Dr. Sampson Antwi
Dr. Daniel Ansong
Dr. (Mrs) Gyikua Plange-Rhule
Dr. Joslin A. Dogbe
Dr. Samuel Blay Nguah
Dr. Charles K. Hammond
Dr. Emmanuel Ameyaw
Dr. Frank Serebour

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LIST OF CONTRIBUTORS
SECTION
1. Paediatric Resuscitation

CONTRIBUTORS
Dr. Justice Sylverken
Dr Charles K.A Poku

2. Neurological disorders

Dr. Charles K. Hammond


Dr. Joslin A. Dogbe
Dr. Justice Sylverken

3. Cardiac Disorder

Dr. Samuel Blay Nguah


Dr. Justice Sylverken

4. Haematological Disorders

Dr. Alex Osei-Akoto


Dr. Justice Sylverken
Dr Daniel Ansong

5. Infectious Disease

Dr. Justice Sylverken


Dr. Daniel Ansong

6. Malnutrition

Dr. Sampson Antwi


Dr. Justice Sylverken

7. Neonatal Disorders

Dr. (Mrs) Gyikua Plange-Rhule


Dr. Priscilla Wobil
Dr. Frank Serebour

8. Fluid and Metabolic Disorders

Dr. Justice Sylverken

9. Oncology Disorders

Dr. Vivian Paintsil


Dr. Alex Osei-Akoto
Dr Charles K. Hammond
Dr. Justice Sylverken

10. Paediatric Emergencies

Dr. Justice Sylverken


Dr. E.O.D. Addo-Yobo

11. Renal Disorders

Dr. Sampson Antwi


Dr. Charles K.A. Poku

12. Respiratory Disorders

Dr. Samuel Blay Nguah


Dr. E.O.D. Addo-Yobo
Dr. Anthony Enimil
Dr. Justice Sylverken

13. Snake Bite

Dr. Justice Sylverken

14. Poisoning in Children

Dr. Justice Sylverken


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1.0 PAEDIATRIC RESUSCITATION


1.1.0 CARDIOPULMONARY RESUSCITATION
INDICATION

Cardiac arrest.

Respiratory arrest.

Cardiopulmonary arrest

No valid Do Not Attempt Resuscitation order.


CONTRAINDICATION

Rigor mortis

Dependent lividity

Corneal clouding

Decapitation

No physiologic benefit can be expected because the patients vital functions have deteriorated
despite maximum therapy for specific conditions.
ASSESSMENT
Rarely is cardiopulmonary arrest (CPA) a sudden event in children. Prior to CPA, signs due to underlying
aetiology will predominate and may include the following:
Tachycardia, bradycardia.
Tachypnoea, dyspnoea, bradypnoea.
Grey, mottled colouring.
Stupor.
Without intervention, patients may progress to:
Apnea.
Pulselessness / asystole.
Cyanosis.
Unresponsiveness.
Dilated, fixed pupils.
Later findings of irreversible death:
Rigor mortis
Dependent lividity
Corneal clouding
INITIAL INVESTIGATION
Blood glucose is mandatory
Other laboratory investigations are rarely useful during CPR, may consider the following;
Blood gases, BUN, creatinine, electrolytes,full blood count, LFTs & toxicology.

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TREATMENT
ABCDs
Rapid and sequential assessment of the ABCs.
a. Airway patency
Insure airway patency, by positioning, suction, adjunctive airways, foreign body removal.
b. Breathing
Use bag-valve mask ventilation, with/without cricoid pressure.
Endotracheal intubation: suction, oxygen, equipment, medication, monitors.
Cricothyriodotomy: for a complete upper airway obstruction only, when unable to orotracheally intubate.
c. Circulation
Chest compressions for patients in cardiac arrest, profound tachycardia / bradycardia (adequately hydrated
child) without a palpable pulse.
Gain intravascular access. Use quickest, largest, most accessible site.
Intraosseous access for asystolic or severely compromised.
Expand intravascular volume with 20ml/kg normal saline or Ringers Lactate
Treat arrhythmias.
d. Drugs
Give 100% oxygen to all patients
Give 10% Dextrose @ 5ml/kg for documented or suspected hypoglycaemia.
Other common resuscitation medications
Use for asystole, profound bradycardia, pulseless ventricular tachycardia (VT),
Adrenaline:
ventricular fibrillation (VF), hypotension due to myocardial dysfunction.
Standard dosage:-Adrenaline (1:10000) first dose 0.1ml/kg IV or IO
Subsequent doses: 0.1ml/kg IV or IO repeat 3-5min (or 10 15:2 CPR cycles )
Contraindication:-Hypertension.
Main side effects:-Tachycardia, arrhythmias.
Atropine:

symptomatic or vagally mediated bradycardia @ 0.02mg/kg (min 0.1mg), Q20min

Lidocaine:

VT, VF frequent PVCs @ 1mg/kg Q5-10min

Naloxone:

suspected opiate overdose @ 0.1mg/kg Q15 30min

Sodium bicarbonate: severe metabolic acidosis (pH 7.2) or prolong CPA.@ 1mEq/kg over 15-30min
Adenosine:

supraventricular tachycardia (SVT) @ 0.05 0.25mg/kg increase by 0.05mg/kg


Q2min up to 0.25mg/kg (or 12mg)

Antibiotics:

suspected infection

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SUMMARY OF ABCD MANEUVERS

Maneuver

Child
1-8years old
Head tilt-chin lift (if trauma is
present, use jaw thrust.)

Infant
<1year old
Head tilt-chin lift (if trauma is
present, use jaw thrust.)

Initial

2 breaths at 1 to 1
sec/breath

2 breaths at 1 to1
sec/breath

Subsequent

12-20 breath/min

20 breath/min

FBAO
Circulation

Heimlich maneuver

Back blows and chest thrusts

Pulse check

Carotid

Brachial or femoral

Compression landmarks

Lower half of sternum

1 finger width below


intermammary line

Compression method

Heel of 1 hand

Airway
Breathing

2 thumbs-encircled hands or
2 or 3 fingers

Compression depth
Compression rate
Compression /ventilation
ratio

1 to 1 in. (2.5-4cm) or
approximately one third to
one half depth of chest
100/min
15:2(Pause for ventilation
until trachea is intubated)

COMPLICATION
Failure to reanimate patient
Pneumothorax
Cardiac arrhythmias
Aspiration pneumonitis
End organ failure

to1in. (1-2.5cm) or
approximately one third to
one half depth of chest
100/min
15:2(Pause for ventilation
until trachea is intubated)

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1.2.0 AIRWAY AND BREATHING MANAGEMENT PROTOCOL

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1.3.0 ASYSTOLE
1.3.1 FIRST STEPS

1.3.2 PULSELESS ELECTRICAL ACTIVITY Not Shockable  Remember PEA

Possible causes consider the 6 Hs and 5 Ts (See Below)


Adrenaline 0.01mg/kg (0.1ml/kg of 1:10,000
1:10
solution) q3-5min IV/IO. Give as soon as possible after CPR
Aggressive Oxygenation 100%

15:2 Compression : Ventilation ratio (Beyond Neonatal period)


Avoid hyperventilation

1.3.3 ASYSTOLE

Not shockable

Remember DEAD

Determine
etermine whether to initiate resuscitative efforts
Adrenaline 0.01mg/kg (0.1ml/kg of 1:10000
1:10
solution) q3-5min
5min IV/IO. Give as soon
s
as possible after CPR s
Aggressive
ggressive Oxygenation 100%
o 15:2 Compression:
Compression Ventilation ratio (Beyond Neonatal period).
period)
o Avoid hyperventilation
Differential Diagnosis or Discontinue
iscontinue resuscitation Are they still dead?
o Consider the 66Hs & 5Ts.
6Hs & 5Ts
Hypovolemia
Tamponade,
amponade, cardia
Hypoxia
Tension
ension Pneumothorax
Hypo
ypo / Hyperkalaemia
Thrombosis
hrombosis (coronary or pulmonary)
Hypoglycaemia
Toxins
Hydrogen
ydrogen Ion (acidosis)
Trauma
Hypothermia
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WHEN TO STOP RESUSCITATION


Resuscitation efforts are unlikely to be successful and can be discontinued if there is no return of
spontaneous circulation at any time after three rounds of medication despite optimal resuscitation effortsusually 30 minutes of cumulative life support, and in the absence of recurring or refractory VF/VT.
Exceptions are patients with a history of poisoning or a primary hypothermic insult in whom prolonged
attempts may occasionally be successful. Prolonged external cardiac compressions provided that central
(femoral arterial) pulses can be felt, may (has) successfully resuscitated children with tricyclic
antidepressant overdoses. Seek expert help from a toxicologist or paediatric intensivist.
BRAIN DEATH
1.
Patient must be normothermic and free from sedative or anticonvulsant drugs
Patients on mechanical ventilation must be re-examined at least 12 -24 hours after the following
2.
clinical features first noticed
Clinical examination criteria
Unresponsive to noxious stimuli (trigeminal distribution)
Fixed dilated pupils
Absent corneal reflex
Absent spontaneous eye movements
Absent oculocephalic (dolls eye) and/or oculovestibular (caloric) reflex
Absent cough to deep tracheal stimulation
Absent suck, gag and rooting reflexes
Absent spontaneous respiratory effort with PaCo2 > 50mmHg
Auxiliary tests
1. EEG
2. Cerebral blood flow study

Respiratory rate (RR), Heart rate (HR), & Systolic blood pressure (SBP) by age at rest
Age

RR

HR

Systolic BP

<1

30 40

110 160

70 90

1 -2

25 35

100 150

80 95

25

25 30

95 140

80 -100

5 12

20 25

80 120

90 110

>12

15 - 20

60 100

100 120

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1.2.0 ANAPHYLAXIS
1. DEFINITION
Clinical syndrome of allergy or immediate generalized or systemic hypersensitivity to a foreign substance
characterized by rapidly developing, life threatening
Airway, and/or
Breathing, and/or
Circulatory problems
Usually with skin and/or mucosal changes.
Anaphylaxis commonly presents as one or more of the following:
Anaphylactic shock
Angioneurotic oedema
Bronchoconstriction
Urticaria
2.

COMMON CAUSES
Drug, vaccines and sera
Blood /blood product transfusions
Insect stings
Food sensitivity
Skin testing
Desensitization

3.

CLINICAL FEATURES
Light headedness
Paraesthesia and pruritus
Sweating, flushing and palpitations
Signs of respiratory distress tachypnoea, apnoea, wheezing, recession, hyperinflation, choking,
stridor, respiratory arrest.
Low peripheral vascular resistance leading to circulatory collapse and profound shock with
hypotension (SBP < 70 + 2[age in years]).

4. TREATMENT
Adrenaline 1:1000
- Give IM @ following doses of 1:1000 [Repeat every 5 minutes if no better]
< 6 months
150 microgram (0.15ml)
6 months 6years
150 microgram (0.15ml)
6 years 12 years
300 microgram (0.30ml)
>12 years
500 microgram (0.50ml)
- OR May give 0.01ml/kg subcutaneously (or dilute to 1:10,000 and give IV / IO @ 0.1ml/kg)
Airway
-Maintain a clear airway
-Ensure adequate oxygenation
-Laryngeal oedema may make endotracheal intubation necessary.
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Bronchodilators for respiratory distress or wheezing


- Salbutamol nebulization Q20min 3 (preferred).
Less than 6 years
2.5mg
6 years and above
5.0mg
(As second line treatment: Aminophylline intravenously @ 5mg/kg/30mins stat, then 1mg/kg/hr.
If patient has been on theophyllines then omit loading dose)

IV Fluids
-Correct hypovolaemia due to massive exudation of intravascular fluids
-Give 0.9% Normal saline or Ringers Lactate (may give Colloids) 20ml/kg/5 -15min
- Monitor response and give further bolus as necessary

Steroids
-Hydrocortisone IV @ 4mg/kg (max. dose 200mg) repeat 6hrly till oral therapy tolerated (24-48hrs)
< 6 months
25mg
6 months 6 years
50mg
6 years 12 years
100mg
>12 years
200mg
-Then oral Prednisolone 1-2mg/kg/day (to complete 2-5 days of steroids)

Antihistamines
-Promethazine (Phenergan)
-0.5-1mg/kg (max. dose 50mg) IM stat or slow IV over 5 minutes.
-Chlorphenamine IM or Slow IV, repeat if required up to 4 times in 24 hours
< 6 months
6 months 6 years
6 years 12 years
>12 years

0.25mg/Kg
2.5mg
5mg
10mg

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ANAPHYLAXIS TREATMENT ALGORITHM

SUSPECTED ANAPHYLAXIS?

ASSESS Airway, Breathing, Circulation, Disability, & Exposure

Sudden onset of illness


Life-threatening Airway and/or Breathing and/or Circulation problems
Skin and/or Mucosal changes

INTRAMUSCULAR (IM) ADRENALINE (1mg/ml) 1:1000


< 6 years
150 microgram (0.15ml)
6 12yrs
300 microgram (0.30ml)
>12yrs
500 microgram (0.50ml)
Repeat IM Adrenaline in about 5 min if no clinical improvement

Place Comfortable
Establish Airway

If clinical signs of shock is a feature Give IV


20ml/Kg bolus of Normal Saline or Lactated
Ringers Solution

If bronchospasm is a major feature


Give inhaled Salbutamol 2.5 -5 mg

AFTER INITIAL RESUSCITATION

CHLORPHENAMINE IM or SLOW IV
<6 months
0.25mg/Kg
6 mth 6 yrs
2.5mg
6yrs 12 yrs
5mg
>12 years
10mg

HYDROCORTISONE IM or SLOW IV
< 6 months
25mg
6 mth 6 yrs
50mg
6yrs 12 yrs
100mg
>12 years
200mg

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10microgram/kg adrenaline IM
-10microgram/kg
-5ml
5ml adrenaline 1/10000 nebulise consider intubation
intubate / su-rgical
su
airway 10microgram/kg adrenaline IM

-10microgram/kg
10microgram/kg adrenaline IM
-2.5 - 5mg nebulise salbutamol repeat
rescue breaths
-rescue
-start
start basic life support
-assess
assess rhythm
-treat
10microgram/kg adrenaline IM
-10microgram/kg
20ml/kg N/S or R/L or colloid IV
-20ml/kg
-hydrocortisone
hydrocortisone 4mg/kg IV
-aminophylline
aminophylline 5mg/kg slow IV
then 1mg/kg/hr IV drip
-2.5 5mg nebulise salbutamol
-10microgram/kg
10microgram/kg adrenaline IM
-20ml/kg
20ml/kg N/S or R/L or colloid IV
-inotropic
inotropic infusion
-10microgram/kg
10microgram/kg adrenaline IM
-5ml
5ml adrenaline 1/10000 nebulise
intubate / surgical airway
-oral/im/iv
oral/im/iv antihistamine
-oral/im/iv
oral/im/iv steroids

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2.0 NEUROLOGICAL DISORDERS


2.1.0 CONVULSIONS / SEIZURE DISORDERS
2.1.1 DEFINITIONS AND CLASSIFICATION

1. DEFINITIONS
Seizure Sudden excessive discharge of neurons in parts of the brain manifested by involuntary motor,
sensory, autonomic or psychic phenomena, alone or in any combination often accompanied by alterations
or loss of consciousness.
Epilepsy Spontaneous recurrent seizures, not related to fever or any acute cerebral insult.
Convulsion Describes sudden and repeated abnormal movements and postures. It is the motor
manifestations of a seizure. It is usually but not always due to epilepsy.
Status Epilepticus Prolonged or recurrent seizures lasting at least 30 minutes without the patient
regaining consciousness.
Epilepsy syndromes Grouping of similar epileptic patients according to seizure type, EEG, age of onset,
familial episodes, prognosis, and other clinical signs.
2. INTERNATIONAL LEAGUE AGAINT EPILEPSY (ILAE) REVISED CLASSIFICATION OF SEIZURES
I. Partial seizures (seizures with focal onset)
A. Simple partial seizures (consciousness unimpaired)
1. with motor signs
2. with somatosensory or special sensory symptoms
3. with autonomic symptoms or signs
4. with psychic symptoms (higher cerebral functions)
B. Complex partial seizures (consciousness impaired)
1. starting as simple partial seizures
a. without automatism
b. with automatism
2. with impairement of consciousness at onset
a. without automatism
b. with automatism
C. Partial seizures evolving into secondarily generalized seizures
II. Generalized seizures
A. Absence seizures (brief lapse in awareness without postictal impairment)
Typical absence
Atypical absence
B. Myoclonic seizures (brief repetitive symmetric muscle contractions)
C. Clonic seizures (rhythmic jerking; flexor spasm of extremities)
D. Tonic seizures (sustained muscle contraction)
E. Tonic-clonic seizures
F. Atonic seizures (abrupt loss of muscle tone)
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III. Unclassified Epileptic Seizures


These include all seizures that cannot be classified because of inadequate or incomplete data and
some that defy classification in hitherto described categories.

2.1.2 GENERAL AETIOLOGY OF CONVULSIVE DISORDERS

1. Congenital

Idiopathic or genetic disorders (e.g. Juvenille Myoclonic Epilepsy)


Neurocutanous disorders (Neurofibromatosis, Tuberous sclerosis)
Metabolic disorders
Congenital malformations of the CNS (e.g. vascular malformations)

2. Acquired

Febrile convulsions
Substance abuse/withdrawal (alcohol/drugs)
Toxicity (drugs, poisons)
Metabolic/electrolyte abnormalities (e.g., hypoglycemia, hypocalcemia)
Perinatal brain injuries (birth asphyxias, intracranial hemorrhage)
CNS infections (meningitis, encephalitis, cerebral malaria)
Trauma (head injuries)
Tumors
Hypoxic/ ischemic stroke
Systemic diseases (e.g. chronic renal failure, chronic liver disease, systemic hypertension,
etc.)

2.1.3 DIAGNOSIS

The diagnoses is of epilepsy is a clinical one, based on history, physical and neurological examinations, and
supported where necessary by appropriate investigation such as electroencephalography, imaging studies
and special studies.
1. History
Previous seizures
Age of onset
Frequency and duration of
Description of ictal event
Seizure type, e.g. Partial vs. Generalizad.
Post-ictal phase
Diurnal pattern
Precipitating event e.g. fever, head injury, etc.
Associated symptoms e.g. headache, incontinence, vomiting, etc.
Any history of accidental drug/chemical ingestion
Past history of birth/neonatal problems
History of systemic illness e.g. SCD, DM, CRF, meningitis/encephalitis, neurocutaneous syndrome
etc.
Developmental delay
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Family history
Seizure diary
Eye-witness account often reliable

2. Physical exam
Rapid survey should include airway, breathing and circulation (ABC)
If seizure is observed by examiner, details should be paid to seizure type, duration, associated signs
and symptoms etc
Look for fever, signs of increased intracranial pressure (high BP, bradycardia, papilloedema)
Look for any offending chemical agent and remove it
Level of consciousness
Detailed neurological examination
o dysmorphic features
o the stigmata of neurocutaneuous disorders (neurofibromatosis, Sturge-Weber)
o evidence of focal neurologic defect
o raised intracranial pressure
Systemic physical exam should be tailored towards possible etiologic factors e.g. CRF,CNS infection,
HTN, Chronic Liver disease, trauma/head injury, genetic disorders, etc
3. Basic investigations
Full blood count
Random blood sugar (RBS)
BUN, Creatinine, serum electrolytes (including Ca2+ , PO42+, and Mg2+)
Liver function test
Toxicology screen (if suspected from history/examination)
2.1.4 ACUTE MANAGEMENT OF SEIZURES / CONVULSIONS

In practice any seizure lasting over 10 minutes should be treated as an EMERGENCY and the doctor
should not leave the patient until the seizures have been stopped.
1. AETIOLOGY: Febrile convulsions
Epilepsy (may be antiepileptic drug withdrawal)
Acute encephalopathy (cerebral malaria, meningitis, hypertension)
Cerebral ischaemia / trauma
Metabolic (hypoglycaemia, uraemia, poisoning, hypo/hyper-natraeremia etc)

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2. INITIAL ASSESSMENT
History

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Examination/Investigation

Previous seizures
generalized or focal
Past medical history
birth/neonatal problems
meningitis/encephalitis
neurological disorder
e.g. neurocutaneous syndrome
or neurodegenerative disorder
developmental delay
trauma
Recent head injury:
Accidental/Non-accidental
-Ingestion of drugs

Nature of convulsion:

Fever

Evidence of trauma
Level of consciousness
Blood glucose electrolyte

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ACUTE MANAGEMENT

Time (min)
0~5

Intervention______________________________
Stabilize the patient
Assess Airway, Breathing & Circulation
Administer oxygen
Check blood glucose
Correct hypoglycaemia if present
Initial screening history & examination

5 ~ 15

Begin pharmacotherapy to stop the seizures


Diazepam
0.5mg/kg per rectum (up to 20mg) or
0.3mg/kg IV slowly over 2-3min (10mg)
Repeat diazepam once if no response in 5-10min

15 ~35

If seizure persists, load with:


Phenobarbitone (max. 200mg)
10-15mg/kg preferable IM(or IV over 30min)

45 ~ 60

If seizure persists 30min after Phenobarbitone, consider:


Additional IM(or IV over 20min) Phenobarbitone
5-10mg/kg (max. total dose 20mg/kg) And/Or
Inj. Phenytoin 15 - 20mg/Kg IV over 20-30min (1.5g/24hrs)

60 ~75

If seizure persists, give either Diazepam infusion


1-2mcg/kg/min (max. dose 5mcg/kg/min)
Or Midazolam infusion
1-2mcg/kg/min (max. dose 4mcg/kg/min)

75 ~90

If no response in 15min after start of infusion,


Prepare for Thiopentone infusion, intubation and
mechanical ventilation and transfer to ICU.

NOTE:a.
b.
c.
d.
e.
f.

All these anticonvulsant drugs may cause or compound pre-existing respiratory depression and
respiratory support may be required.
Give Paraldehyde, if available, at 0.4ml/kg per rectum (mixed with equal volume of
mineral/vegetable oil) after the repeated dose of Diazepam.
May give loading dose Phenytoin @15-20mg/kg/30min, after Phenobarbitone.
Wean off anticonvulsant infusion as quickly as possible once seizures stop.
Measure Blood Pressure to exclude hypertensive encephalopathy.
ASSESS THOROUGHLY once seizure is controlled (stopped).
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3. ONGOING MANAGEMENT:Monitor coma score, respiratory state, temperature, HR & BP(record in notes)
a.
Control temperature with tepid sponge and regular antipyretics
b.
c.
Treat the underlying cause e.g. cerebral malaria, meningitis, encephalitis, electrolyte imbalance
etc.
d.
Do not over hydrate.
If fits last >20min or recurrent, give maintenance long acting anticonvulsant e.g.
e.
Phenobarbitone 2.5mg/kg/dose Q12h.
Phenytoin 5mg/kg/dose Q12h.
2.1.5 OTHER INVESTIGATIONS TO SUPPORT DIAGNOSIS OF EPILEPSY

a. Electroencephalography (EEG)
EEG, where available, is critical to the diagnosis of epilepsy. Methods of recording include:
Routine
Activated (Hyperventilation, Photic Stimulation)
Sleep deprived
24-hr ambulatory
Medication discontinued
Placebo induction
EEG video monitoring
Electrode depth/type

Typical EEG findings in some epileptic syndromes are


Simple partial seizures focal sharp or slow waves (interictal), rhythmic discharge or often
normal (ictal)
Complex partial seizures sharp waves or spikes (interictal), focal or bilateral rhythmic
sharp waves (interictal)
Tonic seizures Flattening/high frequency discharge
Atonic seizures Slow spike-wave/flattening
Tonic-clonic seizures Variable, often obscured
Absence Seizure 3 Hz/sec spike waves (hyperventilation sensitive)
Rolandic Seizure Spikes in the Rolandic area ( centrotemporal region)
Infantile spasms (West Syndrome) Hypsarrhythmias (interictal)
Juvenile myoclonic epilepsy generalized polyspike-wave discharges
b. Neuroimaging (structural/anatomic) studies
Computed tomography (CT) scan
Magnetic Resonance Imaging (MRI)
Indication for imaging in children with epilepsy include
1. Seizures commencing first year of life

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2. History or physical exam suggests an abnormality of CNS e.g. neurocutaneous


syndrome.
3. Developmental delay or regression
4. Persistent or localized slow-wave changes or spike wave foci suggesting a focal
lesion
5. Changes in seizure pattern
6. Refractory seizures may detect glioma
7. Child with previous normal scan but remains poorly controlled (no later than 12
18 months)
MRI in comparison to CT is a superior diagnostic tool in epilepsy. Better image resolution and
lack of beam hardening artifacts from surrounding bone, especially for structures in the
middle fossa (temporal lobes) make MRI a superior structural imaging modality for patients
with partial seizures. Specialized MRI sequences enable detection of small structural lesions in
patients with epilepsy
c. Special investigations (where available) include
Positron emission tomography (PET)
Single photon emission controlled tomography (SPECT)
Magnetoencephalography (MEG)
Intensive CCTV EEG telemetry monitoring

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2.1.6 DIFFERENTIAL DIAGNOSIS

There are recurrent events that mimic epilepsy and should be ruled out before the diagnosis of epilepsy is
made. Some of these events are:
Event
Pseudoseizure
(psychogenic seizure)

Differentiation from epilepsy


No EEG changes except movement artifact during event; movement
thrashing rather than clonic; brief/absent post-ictal periods; most
likely to occur in patient with epilepsy

Paroxysmal vertigo
(toddler)
GER in infancy

Patient frightening and crying; no loss of awareness; staggers and


falls; vomiting, dysarthria
Paroxysmal dystonic posturing associated with meals (Sandifers
syndrome)
Breath-holding spells (18 Loss of consciousness and generalize convulsion always
mo 3 yr)
provoked by an event that makes child cry
Syncope
Loss of consciousness with onset of dizziness and clouded or tunnel
vision; slow collapse to floor; triggered by posture change, heat,
emotion, etc.
Cardiogenic syncope
Abnormal EEG/Holter monitor finding (e.g. prolonged QT, AV block,
other arrhythmias); exercise a possible trigger; episodic loss of
consciousness without consistent convulsive movement
Cough syncope
Prolonged cough spasm during sleep in asthmatic, leading to loss of
consciousness, often with urinary incontinence
Paroxysmal dyskinesias
May be precipitated by sudden movement or startle; not
accompanied by change in alertness
Shuddering attacks
Brief shivering spells with continued awareness
Night terrors (4-6 yr)
Brief nocturnal episodes of terror without typical convulsive
movement
Rages (6-12 yr)
Provoked and goal directed anger
Tics/habit spasms
Involuntary, nonrhythmic, repetitive movements not associated with
impaired consciousness; suppressible
Narcolepsy
Sudden loss of tone secondary to cataplexy; emotional trigger; no
postictal state or loss of consciousness; EEG with recurrent REM
sleep attacks
Migraine (confusional)
Headache or visual changes that may precede attack; family history
of migraine; autonomic or sensory changes that mimic seizure; EEG
with regional area of slowing during attack

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2.1.7 ANTIEPILEPTIC DRUG (AED) THERAPY

Principles of therapeutics
1. Be certain of the diagnosis
2. Decide whether to treat or not to treat
3. Select the best drug appropriate to both the seizure type and the patient
4. The main goal of treatment should be to achieve seizure control with least side effects
5. Start with low doses and gradually push the dose to clinical toxicity or seizure control
6. Use the least expensive AED (all things being equal, like efficacy)
7. Withdraw AEDs that are not effective
8. Prefer AEDs which can be taken od over bid, tid or qid dosing
9. Monotherapy is always preferred (never have a patient on more than 3 AEDs). Polypharmacy is
expensive, increases side effects and increases the complexity of adjusting AEDs in the refractory
patient.
10. Decide when to stop treatment

How to Start a New Drug


Give clear instructions, preferable written
Warn about side effects
Often start bid dosing with night time dose
Increase dose every 2 weeks
Aim for about 2/3 of max. target dose or lowest effective dose
If possible continue max. dose for weeks before abandoning
Avoid chopping and changing
Beware of interactions
Titrate dose over weeks
Warn about problems during change over
Push drug dose if necessary to:
Effective dose
Limits of tolerance

Traditional AEDs

Carbamazepine
Phenobarbitone

Sodium valproate
Ethosuximide

Phenytoin

Felbamate
Topiramate
Tiagabine

Levetiracetam
Gabapetin
Zonisamide

Newer AEDs

igabatrin
Lamotrigine
Oxcarbazepine

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SEIZURE TYPE AND CHOICE OF AEDs


SEIZURE TYPE
Generalized tonic
clonic seizures

1ST LINE
Carbamazepine
Sodium valproate

2ND LINE
Phenobarbitone
Phenytoin

Partial seizures

Carbamazepine
Sodium valproate

Phenobarbitone
Phenytoin

Childhood absence

Ethosuximide
Sodium valproate

Benzodiazepine
Acetazolamide

Myoclonic seizures

Sodium valproate

Atonic seizures

Sodium valproate

Lamotrigine

Infantile spasm (West


syndrome)

ACTH
Prednisolone
Clonazepam
Sodium valproate
Vitamin B6
Sodium valproate
Clonazepam
Steroids
SALT (Speech and
Language therapy)
Carbamazepine

Vigabatrin
Lamotrigine
Topiramate

Lennox Gastaut
syndrome
Landau-Kleffner
Syndrome
Rolandic Epilepsy

Ketogenic diet

NEW ALTERNATIVES
Topiramate
Lamotrigine
Oxcarbazepine
Gabapetin
Tiagabine
Topiramate
Lamotrigine
Gabapetin
Oxcarbazepine
Zonisamide
Vigabatrin
Lamotrigine
Zonisamide
Topiramate

Lamotrigine
Topiramate

Surgery

Sodium valproate

Common side effects of AEDs


Carbamazepine double/blurred vision, vertigo, GI upset/diarrhoea, performance impairment
Sodium valproate GI upset, weight gain, hair loss, tremor
Phenytoin gingival hyperplasia, ataxia, incordination, nystagmus, hirsutiam
Phenobarbital sedation/lethargy, cognitive impairment, behavioural changes/hyperactivity, ataxia
Lamotrigine maculopapular rash
Topiramate renal stones, oligohydrosis, weight loss, ataxia, somnolence, concentration/attention
difficulty
Vigabatrin persistent visual field constriction

Therapeutic Drug Monitoring


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NB. "Routine" levels on controlled, nontoxic patients are not indicated


Check serum levels of AEDs only when necessary to assess:
1. Poor clinical control (compliance, metabolism)
2. Dose-related side effect
3. Drug or disease interaction
AED Idiosyncratic Reactions
Rare
Dose independent
Unpredictable
Usually appear in first 3-6 mo
May recur
Possibly life threatening, include the following:
o Stevens-Johnson
o Aplastic anaemia
o Hepatic failure
o Dermatitis/rash
o Pancreatitis
o Agranulocytosis
o Serum sickness
In the event of treatment failure, the following should be considered
1. Is the diagnosis of epilepsy certain?
2. Is the diagnosis of the type of epilepsy a correct one?
3. Are all episodes which are being recorded as seizures truly such?
4. Is compliance with treatment adequate?
5. Have appropriate drugs each been used in maximal doses?
6. Have appropriate combinations of drugs been tried?
7. Could the patients condition improve by having the number of drugs decreased or stopped?
8. Treatments other than anti- epileptic drugs
STOPPING ANTICONVULSANT THERAPY
Withdraw gradually after a 2 year period of no seizures, preferably over a period of 4-6 months.
Risk of relapse is 20% in children
KETOGENIC DIET
High fat diet designed to mimic the metabolic effects of starvation
Mechanism of seizure control is unknown
Protein and Carbohydrate is restricted
80% of calorie supplied by fat
Most effective in children aged between 2 5yrs
Effective in refractory epilepsy

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o vomiting
o constipation

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o
o

acidosis
high serum cholesterol

o
o

renal stones
growth restriction

2.1.8 SURGERY FOR EPILEPSY

Temporal lobectomy

Hemispherectomy

Corpus Callostomy

2.1.9 PSYCHOLOGICAL MANAGEMENT

1. Prevent or reduce emotional stress


2. Counsel directly children over 8years
3. Orientate parents and family
4. Encourage normal mental and physical activities
5. Safety restrictions must be individualized
6. Contact sports (football, karate)must be avoided
7. Encourage supervised sports (basketball, swimming)
8. Most patients can drive a car at a legal age
9. Reduce constipation with high fibre diet
10. Should have a regular life style with drugs, food, rest, sleep
11. Children with refractory myoclonic and absences may be placed on modified high fat diet
12. Seizures appear to be associated with excessive ingestion of food or fluids
13. Recognition and management of associated learning, language, behavioral, neuromotor
disorders are important aspects of the comprehensive management of the patient with
epilepsy
2.1.10 OTHER PROBLEMS ASSOCIATED WITH EPILEPSY THAT NEED THE PHYSICIANS ATTENTION

1. Epilepsy and learning


Children with uncomplicated epilepsy lag one year behind their peers (Yule 1980).
They also have deficits of reading (severe in 20%), spelling and maths (Seidenberg et al 1986)
2. Epilepsy and psychosocial factors
Stigmatization
Parental anxiety
Social isolation
3. Epilepsy and behaviour
Behaviour problems in 50% attending neuroclinic
Hyperactive, self injurious, mixed conduct/emotional disorder

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2.1.11 INTEGRATED EPILEPSY SERVICE (MULTI-DISCIPLINARY)

Paediatric neurologist
Nurse specialist
Neuro-psychiatrist

Support worker
Psychologists

Special needs teacher


Neurosurgeon

It is essential to adopt a multidisciplinary approach in the management of the child with epilepsy, while the
child remains under the care of a Paediatric Neurologist.
2.1.12 OUTCOME OF TREATMENT

2/3 of children with epilepsy will have seizures controlled with a single antiepileptic drug

2/3 of children with epilepsy are able to attend normal schools

10 years after diagnosis, 30% of patients with epilepsy will be without seizures and on no medication

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2.2.1 ACUTE FLACCID PARALYSIS


DIFFERENTIAL DIAGNOSIS
1. Paralytic poliomyelitis
2. Guillain-Barre syndrome
3. Transverse myelitis
4. Traumatic sciatic neuritis
5. Hysterical paralysis
History and physical findings
CONDITION
HISTORY
Paralytic
Prodromal symptoms of
poliomyelitis
fever, malaise, cough,
abdominal pain, neck pain,
backache, and pain in
lower limb

Guillain-Barre
syndrome

Paralysis follows nonspecific viral infection.


Weakness is ascending in
nature, beginning in the
lower extremities and
progressively involving the
trunk, the upper limbs and
finally the bulbar muscle

Transverse
myelitis

Preceding infection
(mycoplasma, parasitic or
viral), followed shortly by
acute symmetric hypotonia
of lower limbs in hours to
days
Paralysis hours to days
after intramuscular gluteal
injection.

Acute
traumatic
sciatic
neuritis

PHYSICAL FINDINGS
Asymmetric paralysis, flaccid
in nature, large muscles
more affected than small
muscles, lower limbs more
affected than upper limbs.
Absent or reduced deep
tendon reflexes.
No sensory loss
Symmetrical flaccid paralysis,
ascending in nature. Bulbar
involvement may result in
facial weakness, dysphagia
and the respiratory failure.
Tendon reflexes are lost, but
are sometimes preserved till
late in the disease.
There may be sensory loss
Symmetric hypotonia in
lower limbs. Early loss of
deep tendon reflexes.
Sensory loss is present

LABORATORY FINDINGS
1. CSF pleocytosis (PMN)
at 2-3 days
2. Positive stool culture
for virus
3. Virus can also be
isolated from throat,
urine and CSF

Asymmetric and paralysis is


complete in the affected
limb. Reduced or absent
deep tendon reflexes with
sensory loss

Normal CSF findings

24

CSF studies show


elevated proteins, normal
glucose, and no
pleocytosis.
2. Negative CSF cultures.

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2.2.2 MANAGEMENT OF POLIOMYELITIS


Acute Phase Management
1. Bed Rest during the first week of admission or until fever resolves. Exercises would worsen
the extent & severity of paralysis. No invasive investigations at this time.
2. Analgesics & hot packs to relieve pain.
3. Keep the limbs in a neutral position & support with sand bags
4. Monitor closely for signs of worsening paralysis and bulbar involvement
5. I.C.U care and mechanical ventilation in cases of bulbar polio
Long Term Management
1. Physiotherapy
2. Use of special ambulatory devices
3. Surgery to correct deformities

2.2.3 MANAGEMENT OF GUILLAIN-BARRE SYNDROME


1. Admit
2. If ascending paralysis is slow in progression, simply observe patient for stabilization and
spontaneous remission without treatment
3. Treat rapidly progressive ascending paralysis with intravenous immunoglobulin.
Plasmapheresis, steroids and immunosuppressive drugs are alternatives.
4. Supportive care such as prevention of decubitus ulcers and treatment of secondary bacterial
infections are important.
5. Observe patient closely for respiratory muscle involvement
6. I.C.U care and mechanical ventilation in cases of bulbar involvement.

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2.3.0 ACUTE ENCEPHALOPATHY / NON TRAUMATIC COMA


1. COMMON CAUSES:Infection
Epilepsy
Vascular
Toxic
Tumor
Metabolic
Temperature regulation

- malaria, meningitis, encephalitis etc


- convulsive or non convulsive
-hypertensive encephalopathy, intracranial haemorrhage etc
-drugs, poisons etc
-benign or malignancy
-hypoglycaemia, hyperglycaemia, hepatic failure etc
-hyperthermia, hypothermia

2. RAPID ASSESSMENT & STABILISATION ( NEUROLOGICAL ABC) :A

-Airway

Ensure there is an adequate airway, best protected by putting the


patient in the recovery position.

-Breathing

Ensure the patient is breathing sufficiently to provide adequate


Oxygenation (SaO2). Give oxygen, artificial respiration if needed.

-Circulation

Check for adequate circulation, with pulse, BP & cap. refill time.

-Diabetes

Check blood sugar - Dextrostix, BM sticks(true blood glucose if


possible) if not available give 4-5ml/kg of 10% dextrose if the
altered consciousness could be due to hypoglycaemia.
Consider overdose or poison.

-Drugs
E

-Epilepsy

Observe for seizures (lift the eye lids and look for tonic deviation
of the eyes or nystagmus) or stigmata, bitten tongue: stop/control
seizures.

-Fever

Check for fever, stiff neck, purpuric rash of meningococcal


meningitis, blood film malaria parasite for cerebral malaria.

-Glasgow
coma scale

Assess coma score. Record sub scores (eyes/verbal/motor) as well


as total.

-Herniation

Is there evidence of conning or raised intracranial pressure?

LOOK for Evidence of Herniation


Respiratory rate & pattern (e.g. Cheyne-Stokes, erratic respiration).
Posture / Tone / Reflexes (include oculocephalic reflex & plantars).
Motor response to pain, decorticate or decerebrate posturing.
Cushings phenomenon (BP, HR and slow irregular breathing).
Papilloedema / Retinal haemorrhage / Cranial nerve palsies.
Pupils size & response to light (including asymmetry)see below.

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www.postgradmed.com/issues/2002/02_02/malik1.gif
3.

FURTHER ASSESSMENT & INVESTIGATION


Obtain history.
DO THOROUGH examination.
Obtain samples for laboratory investigation (e.g. Blood for MPs, FBC, C/S glucose, electrolyte, LFTs,
Renal functions etc).
LP for CSF examination if cardiopulmonary stable, no local infection at LP site
site, no focal neurological
signs
igns or signs of raised intracranial pressure (apart from bulging fontanelle).
Monitor Pulse, BP, Respiration rate and pattern, Temperature, Coma score,
Brain stem function
and Blood glucose.

4. TREATMENT
Ensure airway is patent
patent, adequate oxygenation (SaO2>95%) & BP (MAP>80mmHg)
If herniation / raised intracranial pressure suspected or present
i. Raise head of bed 30o and give oxygen.
ii. Give mannitol IV infusion @ 0.25 - 1g/kg over 30mins Q6-8h
iii. Steroids useful in vasogenic oedema (avoid in cerebral malaria, hypertensive
encephalopathy & herpes encephalitis) give Dexamethasone IV @ 0.4-1mg/kg
stat, then 0.15mg/kg/dose q6h; (max dose 16mg/24hr.)
If cause is established
established, treat accordingly. Otherwise may manage as cerebral malaria
Treat what is treatable
treatable.
Treat hyperthermia /hyperpyrexia
/hyperpyrexia.
Restrict fluid to 70% maintenance, after adequate hydration [or
[ maintain normotension].
Maintain an adequate cerebral perfusion with mean blood pressure >80mmHg
DO NOT give fluids containing no sodium to patients with meningitis unless you are just
keeping the line open.
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2.3.1 SOME COMMONLY USED COMA SCALES


Blantyre Coma Scale
Best motor response:

Verbal response:

Eye movements:

Localizes painful stimulus


Withdraws limb from pain
Nonspecific or absent response
Appropriate cry
Inappropriate cry or moan
Non
Directed (e.g. follows mothers face)
Not directed

2
1
0
2
1
0
1
0

Total

0-5

Child's Glasgow Coma Scale (<4 years)


Response

Score

Eye opening
4
3
2
1

Spontaneously
To verbal stimuli
To pain
No response to pain
Best motor response

6
5
4
3

Spontaneous or obeys verbal command


Localizes to pain or withdraws to touch
Withdraws from pain
Abnormal flexion to pain
(decorticate)
Abnormal extension to pain
(decerebrate)
No response to pain

2
1

Best verbal response


5
4
3
2
1

Alert, babbles, coos, words to usual ability


Less than usual words, spontaneous irritable cry
Cries only to pain
Moans to pain
No response in pain

3 - 15

TOTAL

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Glasgow Coma Scale (4-15 years)


Response

Score

Eye opening
4
3
2
1

Spontaneously
To verbal stimuli
To pain
No response to pain
Best motor response

6
5
4
3

Obeys verbal command


Localizes to pain
Withdraws from pain
Abnormal flexion to pain
(decorticate)
Abnormal extension to pain
(decerebrate)
No response to pain

2
1

Best verbal response


5
4
3
2
1

Orientated and converses


Disorientated and converses
Inappropriate words
Incomprehensible sounds
No response to pain

3 15

TOTAL

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3.0 CARDIAC DISORDERS


3.1.0 ACUTE HYPERTENSION
DEFINITION
Pre-hypertension:- BP between 90th and 95th percentile for age, sex & height ( i.e. 90th < BP 95th %tile)
Significant hypertension:- BP > 95th percentile
Stage 1 hypertension:- 95th percentile < BP [(99th percentile for age, sex & height) + 5 mmHg]
Stage 2 Hypertension :- BP > ([99th percentile for age, sex & height] + 5 mmHg)
Hypertensive urgency: - significant elevation in BP without end organ damage.
Hypertensive emergency: - significant elevation in BP with acute end organ damage.
Blood pressure in childhood
Age
Significant hypertension(mmHg)
Severe hypertension(mmHg)
(Years)
Systolic
Diastolic
Systolic
Diastolic
At birth
96
106
<2
112
74
118
82
3-5
116
76
124
84
6-9
122
78
130
86
10-12
126
82
134
90
13-15
136
86
144
92
16-18
142
92
150
98
Blood pressure approximations in childhood;
50th centile Systolic Blood Pressure (SBP)
~ [90 + 2Age (years)] mmHg
th
~ SBP
50 centile Diastolic Blood Pressure (DBP)
Severe hypertension ~
> [20mmHg + 50th centileBP]
1. COMMON CAUSES OF HYPERTENSION
Newborn infants:
Renal artery stenosis / thrombosis, congenital renal malformations,
coarctation of the aorta, bronchopulmonary dysplasia.
Infants / Toddlers:
Renal parenchymal diseases, coarctation of the aorta, renal artery
stenosis
6-10 years old:
Renal parenchymal diseases, renal artery stenosis, 1o hypertension
Adolescence:
Renal parenchymal diseases, 1o hypertension
2. ASSESSMENT
History
Headache, blurry vision, epistaxis, chest pain
Examination
Skin lesions e.g. caf-au-lait spots, neurofibromas, rashes
Evidence of Congestive heart failure:-crackles, tachycardia, gallop rhythm, hepatomegaly, oedema
Weight gain or loss / unusual body habitus
Abdominal mass or bruit
Evidence of virilization or cushingoid effect
Obtain four-extremity BP with appropriate-sized cuff and femoral pulse.
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Investigation
Serum electrolyte and renal function studies
Echocardiogram and renal ultrasound Doppler
Chest radiograph, CT angiogram and ECG
3. COMPLICATIONS
 Congestive heart failure
 Renal failure
 Encephalopathy
 Retinopathy
4. MANAGEMENT/DRUG TREATMENT
Indicated in severe hypertension (as defined above) and/or significant hypertension with end organ
damage.
Rule out hypertension 2o elevated ICP before lowering BP
Mean Arterial Pressure (MAP) = SBP + DBP
Hypertensive emergency:
MAP should be lowered by of planned reduction
st
over 1 6hr, an additional 3rd over the next 24-36hr
and the final 3rd over the next 48hr.
Hypertensive urgency: Aim to lower MAP by 20% over 1hr. oral or
sublingual routes may be adequate.
Monitor BP, HR, & RR more frequently at the start of drug therapy.

Drug
Hydralazine

COMMON MEDICATION FOR HYPERTENSIVE URGENCY / EMERGENCY


Route
Dosage
Comments
(PO,IV,IM)
0.1-0.2mg/kg/dose
Adjust dose in renal failure
IM/IV Q4-6hr (20mg/kg)
1 - 3mcg/kg/min (max. 150mcg/kg/min)
0.75-1mg/kg/day PO Q6-12hr

Nifedipine

(PO,SL)

Amlodipine

(PO)

0.25-0.5mg/kg/dose PO/SL Retard preparation may be


(20mg/dose) Q4-6hr PRN
given Q 12-24 hrly
0.2mg/kg/day. Q24Hrly

Atenelol

(PO)

Methyldopa

(PO)

Frusemide

(PO,IV)

Captopril

(PO)

May give Q12-24hrly in Young Chn

1-2mg/kg/12-24hourly
10mg/kg/24hr Q6-12hr;
Adjust dose in renal failure
Increase PRN Q 2 days (3g/day). May interfere with test for
creatinine.
0.5-2mg/kg/dose Q6-12hr
May cause K+
(6mg/kg/dose)
caution in hepatic disease

0.1-0.3mg/kg/dose titrate upward Adjust dose in renal failure


(6mg/kg/day QD - QID)
Taken on empty stomach
Note: If repeated dose of any of these drugs are required, start ORAL MAINTENANCE THERAPY
as soon as possible
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3.2.0 HEART FAILURE


Definition
Inability of the heart to deliver adequate cardiac output to meet bodily needs
Symptoms/Signs
Infants
Diaphoresis
Wheezing
Hepatomegaly
Cardiomegaly
Irritability

Tachypnoea,
Feeding difficulties
Poor weight gain
Weak cry
Gallop rhythm

Abdominal pain
Exercise intolerance
Raised JVP
Cardiomegaly

Recurrent pneumonia
Abnormal heart sound
Oedema (usually eyelids and sacrum)
Noisy labored breathing

Children

Fatigue
Dyspnoea
Cough
Orthopnea

Abnormal heart sounds


Basal crackles
Gallop rhythm
Oedema (usually dependent)

Investigations
Pulse oximetry Helps with oxygen administration and establishing diagnosis
Chest x-rayCardiomegaly, pulmonary oedema
ECGHelps to establish diagnosis
EchocardiographyTwo dimensional to determine:
Fraction shortening (FS):
Normal =28%-40%
Ejection fraction (EF):
Normal =55% - 65%
Determine other cardiac deformities.
Biochemistry
Sodium, Potassium
Serum B-type natriuretic peptide (BNP)
Management
General measures
1. If Orthopnea present -may rest on pillows
2. Strict bed rest rarely needed but must have adequate rest
3. Strenuous exercise may be curtailed often temporarily and depending on etiology
4. Diet: Encourage appropriate feeding. Patients with failure to thrive should be given added calories
to be achieved by increasing frequency of feeding. NG tube feeding may have to be done to achieve
appropriate feeding.
5. Drug treatment
a. Acute heart failure:
IV furosemide 1-4mg/kg PRN
b. Chronic heart failure:
PO furosemide 1-4mg/kg/day od-qid
and spirinolactone 1-3mg/kg/day od-tid
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c. The following drugs may be added to the two above in consultation.


Digoxin: ( IV dose is 75% of PO dose)
Digitilization (po, TDD initially, followed by TDD q12h 2):
Infant or child: 2540 mcg/kg
Adolescent or adult: 0.51 mg in divided doses
Maintenance
510 g/kg/day, divided q12h
Captopril ( PO)
Infants: 0.10.5 mg/kg/dose q812h (maximum, 4 mg/kg/day)
Children: 0.12 mg/kg/day q812h (adult dose is 6.2525mg/dose)
Enalapril (PO)
0.080.5 mg/kg/dose q1224h (maximum, 0.5 mg/kg/day)
Prazosin (PO)
PO:0.0050.025 mg/kg/dose q68h (maximum, 0.1 mg/kg/dose
Carvedilol (PO)
Initial dose 0.1 mg/kg/day (maximum 6.5 mg) divided bid, increase gradually
(usually 2 wk intervals) to maximum of 0.51 mg/kg/day over 812 wk as tolerated;
adult maximal dose, 50100 mg/day
6. Counsel parent and advice on surgical treatment if indicated.
7. Monitor Heart failure with the scoring system in the table below:
Modified Ross Score - For Heart Failure
Score (Points)
History
Diaphoresis
Tachypnoea
Physical examination
Breathing
Respiratory rate (per min)
0-1yr
1-6yrs
7-10yrs
11-14yrs
Heart rate (per min)
0-1yr
1-6yrs
7-10yrs
11-14yrs
Hepatomegaly(liver edge)

Head only
Rare

Head and Body during exercise


Several times

Head and body at rest


All the time

Normal

Retractions

Dyspnoea

<50
<35
<25
<18

50-60
35-45
25-35
18-28

> 60
>45
>35
>28

<160
< 105
<90
<80

160-170
105-115
90-100
80-90

>170
<115
>100
>90

<2cm

2-3cm

>3cm

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3.3.0 INFECTIVE ENDOCARDITIS (IE)


Definition:
Infection of the endocardium (+heart valves) by bacterial, viral, fungal and other microbes. Most often
caused by Streptcoccus viridians and staphylococcus aureus
Symptoms/signs
Often History of congenital heart disease, rheumatic heart disease, surgery-dental, urinary tract,
intestinal, central venous catheter.
Fever, chills, abdominal pain, myalgia, arthrigia, dyspnoea, malaise weight loss, night sweats.
Tachycardia, Embolic phenomena (Roth spots, petechiae, splinter nail bed hemorrhages, Osler
nodes, CNS or ocular lesions), new r changing murmur, splenomagaly, arthritis, heart failure,
clubbing.
Modified dukes criteria as a diagnostic tool
Two major or one major and three minor or five minor criteria is diagnostic of infective endocarditis.
1. Major criteria
Positive blood cultures (two separate cultures for a usual pathogen, two or more for
less typical pathogens)
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)
2. Minor criteria
Fever
Predisposition congenital heart disease, IV drug use, recent surgery, central catheter
use.
Embolic vascular phenomenon - major arterial emboli, septic pulmonary infarcts,
mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway
lesions
Immunologic phenomena - glomerulonephritis, Osler's nodes, Roth spots , and
rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major criterion as
noted in the major criteria
Serological evidence of active infection with organism consistent with IE
Echocardiographic findings: consistent with IE but do not meet a major criterion as
noted above
Newly diagnosed clubbing
Splenomegaly
Splinter hemorrhages, and petechiae
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Presence of central non-feeding lines
Presence of peripheral lines
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Investigations:
Blood C/S three times preferably at the peak of the fever and before starting antibiotics
FBC (Hb, WBC), C-reactive proteins, ESR,
Urine R/E (hematuria)
Chest X-ray (bilateral infiltrates)
Echocardiography vegetations, valve dysfunction
Management
Start antibiotic as soon as possible
o Gentamycin:
5mg/kg/dose daily PLUS
o Penicillin:
300,000U/kg/day in 4-6 divided doses PLUS
o Flucloxacillin: 100mg/kg/day in 4 divided doses
Further treatment based on antibiotic sensitivity
Treat for at least 4 weeks (even if fever settles within a week)
Treat heart failure as per the heart failure protocol
Endocarditis prophylaxis
 Oral Amoxyl 40mg/kg at least 1hr before surgery OR
 IV/IM Ampicillin 50mg/kg 30mins before procedure OR
 Oral clindamycin 20mg/kg 1 hr before procedure OR
 Oral azithromycin 15mg/kg one hr before procedure

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3.4.0 RHEUMATIC HEART DISEASE


Definition
This is inflammation of the endocardium and valves of the heart secondary to rheumatic fever. In
decreasing order the valves affected are mitral, aortic, tricuspid, and pulmonary valves.
Symptoms/signs
Most cases are mild to moderate and usually are not symptomatic but patients often seen at KATH
are the severe ones
Predominantly have signs of mitral regurgitation (MR), stenosis and mixed regurgitation and
stenosis
Pansystolic murmur radiating to the axilla often present with MR.
Mid-dastolic rumble indicates increased flow across mitral valve
Mitral stenosis (MS) often present later in the disease and associated with a longer diastolic
murmur
Other signs of heart failure described on page 32 may be present especially in severe disease
Investigations
Chest x-ray: often shows cardiomegaly with mitralization of the left ventricle. Pulmonary artery
enlargement may also be seen
ECG: p wave abnormalities (notched, tall) and features of left ventricular enlargement, arrhythmia.
Echocardiography
Management
In all cases
o Prophylaxis against rheumatic fever
a. IM Benzathine penicillin 1.2mu 3-4weekly for life or
b. Penicillin V 250mg bid for life or
c. Erythromycin 250mg bid for life
o Repeat echo every six months to one year
MR - moderate to severe (often associated with symptoms)
o Prophylaxis against rheumatic heart disease
o Treat arrhythmia as indicated
o Endocarditis as indicated in the section on endocarditis
o Heart failure as indicated in the section on heart failure. Here predominantly ACE inhibitors
such as lisinopril and captopril are preferred.
o Surgical repair cand be sought but valve replacement shuld be delayed as long as possible if
well controlled by drugs alone till patients is 18yrs and older
MS moderate to severe
o Temporarily treat with decongestive drugs diuretics
o Advice surgical repair/ balloon angioplasty as early as possible
Aortic insufficiency
o Often well tolerated so may require ACE inhibitors
o Valve replacement may be considered in severe case when patient is >18yrs
Pulmonary and tricuspid valves diasese
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Often responds to appropriate treatment of the left sided lession

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3.5.0 TETRALOGY OF FALLOT (TOF) AND HYPERCYANOTIC (TET) SPELL


Definition:
Cyanotic congenital heart disease characterized by
1. VSD
2. Right ventricular outflow tract obstruction
3. Right ventricular hypertrophy
4. Overriding aorta
Hypercyanotic spells is a sudden onset of paroxysmal hyperpnoea, irritability, increasing cyanosis and
decreased intensity for heart murmur in children often less than a year with TOF.
Signs/Symptoms
TOF: Dyspnoea on exertion, cyanosis (variable and often not present at birth), squatting, tachypnoea,
tachycardia, clubbing, polycythemia (plethora), ejection systolic murmur, stunting
tet spell: Tachypnoea, hyperpnoea, irritability, increasing cyanosis, unconsciousness, decreased intensity for
heart murmur, hemiparesis,
Investigation
N.B: not all cyanotic congenital heart diseases are Tetralogy of fallot!!
TOF:
1.
2.
3.
4.

Chest x-ray typical boot shape


ECG right axis deviation
Echocardiography usually diagnostic
Full blood count - Hb, WBC

Tet spell: blood chemistry-pH, HCO3-,


Management
TOF stable state
1. Regular (6monthly reviews)
2. Iron 3mg/kg/day
3. May need to put infants with frequent tet spells on oral Propranolol
4. Appropriate feeding advice
5. Phlebotomy based only on Hemoglobin remains controversial so do not perform till patient has
signs of polycythemia.
TOF with tet spell
1. Place in knee chest position
2. Administer oxygen (has limited value so do not force it if infant combative)
3. IM/sc morphine 0.1-0.2mg/kg stat
The above usually aborts the attack but if persistent continue with the following
4. IV Propranolol 0.1-0.2mg/kg as slow IV push
5. Correct acidosis if present with 1mEq/kg IV.
Remember to discharge home on iron supplements!!

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4.0 HAEMATOLOGICAL DISORDERS


4.1.0 SICKLE CELL DISEASE
Definitions
- Sickle cell disease: hemoglobinopathies characterized by the formation of sickled red cells in
response to deoxygenation
- Sickle cell anaemia: substitution of valine for glutamine in the 6th amino acid position of the chain.
- Others: HbSC, sickle-thalassemia combination.
- All sickle cell patients should be considered as immunocompromised host.
Therapy:
1. Stabilization: ABCs, treat shock, frequent reassessment
Maintain adequate hydration, monitor volume status DO NOT over hydrate
2. Hydration:
relaxes patient, and enhances pulmonary toilet.
3. Liberal pain control:
4. *Treat infection
Antimalarial: consider local resistance & sensitivity pattern (e.g. Give Quinine or ACT)
Antibiotics:
must provide coverage for encapsulated organism
(e.g. Strept. pneumoniae, H. influenzae) & others like Staphylococcus, Salmonella
5. *Haemotransfusion:

partial exchange/straight transfusion (see anaemia transfusion)

ASSOCIATED ACUTE ILLNESS:


GENERAL PRINCIPLES OF MANAGEMENT IN ACUTE EPISODES
o Make sure diagnosis of SCD has been confirmed by relevant laboratory findings
o Take cognizance of presence or otherwise of any long term complications of SCD e.g. Renal
Failure.
o Always do routine tests for established patients.
o Look for source of infection by doing Blood cultures, thick/thin film for MPs, Urine R/E etc.
o Prescribe a curative antimalarial according to National Protocol
o Prescribe appropriate antibiotics if infection is present
o Relieve distress
o Aim to improve vascular blood flow by ensuring adequate hydration
o Aim to mobilize patient early
4.1.1 INFECTION (MALARIA/SEPSIS/PNEUMONIA/OSTEOMYELITIS/UTIS ETC)

Clinical Assessment:

Management:

fever and/or other signs/symptoms of infection


FBC + B/F for MPs, blood & urine C/S
CXR, LP if indicated & no contraindication(s)
ABCs, freq. reassessment, hydration, analgesics antimalarial,
antibiotics, O2.
DO NOT delay antibiotics while waiting for C/S

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Acute Osteomyelitis:
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Staphylococcus species
Salmonella
species

Investigations:
1. Bone marrow culture an infection site Needle aspiration
2. Blood culture/sensitivity
3. Stool culture/sensitivity
4. Rule out Kochs disease
5. X-ray of affected bone Changes seen about 10-14 days after onset
Treatment:
Initial therapy before culture and sensitivity results should cover both staphylococcus and samonella
species. Fair choice antibiotics include clindamycin, vancomycin for staphylococcus and
chloramphenicol for salmonella. Other useful antibiotics for salmonella include thrimethoprimsulfamethoxizole, aminoglycosides, 2nd and 3rd generation cephalosporins and ciprofloxacin in adults.
Duration of therapy About 4 6 weeks
Parenteral antibiotics is necessary in the first 10 days
Hand Foot Syndrome:
Treatment
1. Analgesics
2. Hydration
3. Parental reassurance
Note Early osteomyelitis can mimic this syndrome
 In the presence of fever, marked inflammation or no clinical improvement after 3 days
Evaluate for osteomyelitis.

4.1.2 HYPERHEMOLYTIC CRISIS

Clinical Assessment:
Management:

icterus, acute drop in Hb, haemoglobinuria FBC, RBCs indices, rectic count
ABCs, O2, serial PCV & urine monitor
Treat infection, hydration transfusion

4.1.3 SPLENIC SEQUESTRATION (MASSIVE RBCS + PLASMA SEQUESTRATION IN SPLEEN)

Clinical Assessment:
Management:

Acute drop in Hb > 2g/dl,anaemia, retic, platelet Pallor, irritable, abd.


pain/distension, intravascular volume. FBC, RBCs indices, rectic count
ABCs, & freq. reassessment
Treat shock, hydration, haemotransfusion, analgesics, antimalarial & antibiotics

4.1.4 APLASTIC CRISIS (CESSATION OF ERYTHROPOIESIS)

Clinical Assessment:
Management:

Hx of URTI signs/symptoms, rapid Hb, retic, pallor, weak


FBC, RBCs indices, rectic count
If stable, monitor closely; spontaneous resolution 1-2weeks
If unstable ABCs, freq. assessment + top-up transfusions
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4.1.5 VASO-OCCLUSIVE CRISIS

Pain
Clinical Assessment:

precipitants; (hypoxia, dehydration acidosis, infection) long bone or abd.


pain, dactylitis (6-12mths) R/o infection, acute abd. and osteomyelitis

Management:
The GOAL of therapy is to provide prompt pain relief.
o Hydration, analgesics & treat infection if present
Assess pain and categorize into:
Mild: Pain limited to a single joint or limb of bearable intensity and without any associated
symptoms/signs e.g. Fever, anaemia.
Should be treated on out-patient basis.
Moderate: Pain affecting multiple sites impairing normal activity without any associated symptoms
or signs.
Can be treated on outpatient basis except where social circumstances of the patient and good sense
indicate otherwise
Severe: Severe pain in single or multiple sites
1. With or without associated symptoms/signs
2. Abdominal crisis (pain)
3. Chest pain
4. Severe headache
Patient must be detained in the first instance (if recovery ward is available) and admitted if
symptoms have not subsided after 24-48 hours.
Mild Moderate Painful Episodes:
o Try to identify the precipitating factor(s)
o Ascertain that the patients temperature is normal
o Investigate thoroughly refer labs for established patients
o Encourage high oral fluid intake
o Start with simple analgesics- e.g. Paracetamol 10mg/kg every 4-6 hrs or Ibuprofen 510mg/kg/dose every 6-8hrs.
Note: Alternating paracetamol and ibuprofen doses 3 hourly offers sustained pain relief
Moderate pain demands the use of higher NSAIDs e.g. Tramadol, Toradol or Codeine.
Ketorolac (Toradol) 1mg/kg load, followed by 0.5mg/kg every 6hrs
o Warm baths, massage and application of warm pads help relieve pain
o Give curative dose of antimalarial
o See patient within 3-5 days to assess and alter management if indicated.
Severe Pain
o Admit patient
o Do Numbers 1-4 under Mild to Moderate pain
o Give IV fluids (N/S or D). Total volume should not exceed 1.5X maintenance requirement
for 24hrs for the patient.
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Give analgesic:
Start with a strong NSAID e.g.: Ketorolac (Toradol) - 1 mg/kg stat, followed by 0.5mg/kg
every 6 hours;
Morphine: Parenteral: 100mcg/kg 4 hourly
80-200mcg/kg 4 hourly
PO:
There should be no PRN regimen
Assess patient frequently- every hour

4.1.5.1 PRIAPISM

Clinical Assessment:
Management:

painful erection, most often seen in adolescents


hydration & analgesics, avoid over hydration, if 4-6hrs no resolution
haemotransfusion & Urology consult

4.1.5.2 ACUTE CHEST SYNDROME (PNEUMONIA/INFARCT)

Clinical Assessment:
Management:

cough, pleuritic chest pain, tachypnea, hypoxia, CXR (changes in lugs)


ABCs, O2, hydration (1X maintenance volume), analgesics, antibiotics
Consider haemotransfusion, mycoplasma, & PTB

4.1.5.3 CVA

Clinical Assessment:

headache, seizure, weakness, altered sensorium


Focal neurologic defecit
Must R/o meningitis, abscess, frontal bone infact
Management:
ABCs, frequent reassessment, O2, hydration antibiotics,
haemotransfusion
Control seizure & ICP
4.1.6 INDICATIONS FOR BLOOD TRANSFUSION:

1. A need to improve oxygen-carrying capacity and transport. Transfusions should be


SIMPLE TRANSFUSION
a. Anaemic patients with impending or overt high output cardiac failure, dyspnoea, postural
hypotension angina or cerebral dysfunction.
b. Acute splenic or hepatic sequestration crisis
c. Hb less than 5gm/dl and PCV less than 15%, associated erythroid hypoplasia or aplasia

2. A need to improve microvascular perfusion by decreasing the proportion of


erythrocytes containing HbS. (Partial exchange transfusion)
a. Acute impending or suspected cerebro-vascular accidents, including transient
ischaemic attacks
b. Arterial hypoxia syndrome (fat embolism)
c. Acute progressive lung disease
d. Unresponsive acute Priapism
e. Eye surgery
4.1.7 CHRONIC COMPLICATIONS

A. Leg Ulcers:
1. Always treat in collaboration with plastic surgeon
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2. Search for other causes of leg ulcers such as varicose veins, diabetes mellitus and collagen
vascular diseases.
3. Radiography of the leg to rule out underlying bony infection
4. Wound swab for culture and sensitivity
5. Daily dressing
Failure to Heal:
1. Try chronic blood transfusions to raise Hb to 10mg/dl for a period of six months.
2. Try skin grafting
B. Aseptic Necrosis:
1. Always treat in collaboration with specialist Orthopaedic Surgeons
2. Radiograph in AP and frog-leg position.
3. In early case and in children in particular
- Avoidance of weight bearing not motion with the use of braces.
- Appliance of local hat and analgesics for up to 6 months
4. In individuals beyond adolescence and with severe aseptic necrosis, surgical replacement may
be considered.
C. Hypersplenism
Diagnosis: - Spleen 4cm or more below coastal margin
- Hb less that 6.5g/dl
- Reticulocyte count above 15
- Platelets count below 2000x109/L
- Observed on 2 occasions 6 months apart.
Treatment:
1. Chronic transfusion programmes
2. Splenectomy preferable refer Surgeon
Equivocal Indication- no clear cut evidence whether transfusion is either useful or necessary.
a. Preparation for surgery requiring general anaesthesia
b. Intractable acute events
c. Before injection of contrast material
D. Chronic Transfusion:
This may be relevant for several chronic conditions related to sickle cell disease. In these cases the
proportion of normal cells circulating should be maintained above 70% by repeated simple
transfusion. Clear indication is for:
- Cerebral vascular occlusion (stroke)
Other less clear indications are:
- leg ulcers
- chronic organ damage
- skin graft
- pregnancy
- extreme diminution of performance status due to recurrent complications of SCD.

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4.2.0 ANAEMIA TRANSFUSION ALGORITHM


Patient with Anaemia
Ensure ABCs, and then draw blood for
FBC, RBCs indices, rectic count
+ Sickle cell & G6PD status blood film comment
Hb <4g/dL or
Hb 4-6g/dL plus respiratory distress
No

Yes

Complete history & Physical exams


Transfuse BLOOD
10-20mL/kg over 3-4 hours
Lasix 1mg/kg at start of transfusion

Acute blood loss or increase destruction?


Yes

(Avoid Lasix if Patient is hypovolaemic)

No

Group & Cross Blood match stand-by


Hb < 6-7g/dL or HCT < 20% PCV PLUS
Acute blood loss or increase destruction
Blood sequestration
Respiratory distress
Shock
Coma
Sickle Cell Disease with
o Acute Sickle Chest Syndrome
o CVA
o Priapism
o Prolong Chest Pain Crisis

Yes
Observe every 15 minutes
Monitor for signs of overload
- Rising PR >25bpm
- Rising RR >5 bpm
Monitor for transfusion reaction
IF signs of overload or reaction
STOP BLOOD
Call for Senior review

No
Review laboratory results with resident/specialist
FBC, RBCs indices, rectic count, Sickle cell & G6PD status Stool R/E, Coombs test, ESR, blood film comment
NOTE
Do proper patient identification before, during and immediate after Blood transfusion
Take 2-3ml blood for grp X-match & label sample ASAP. DO NOT pre-labeling sample
Capillary haematocrit (PCV) is 1-2% higher than venous haematocrit (PCV)
If bleeding GI /Surgical  Control blood loss PLUS Senior Review
Monitor RBS hourly if previously Hypoglycaemic, Severe Malaria, or on Quinine inj.
Give 1st 5ml/kg of blood over 30min if in Shock or Haemodynamically unstable.
Complete blood transfusion monitoring sheet
If in doubt call for Senior Review
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5.0 INFECTIOUS DISEASES


5.1.0 MENINGITIS
1. DIAGNOSIS:
Bacterial infection of the meninges = bacterial meningitis
High index of suspicion as symptoms can be subtle, especially in infants.
Symptoms may include headache, neck pains, neck stiffness, irritability etc.
LP for CSF -Cellular CSF (>5 wbc) with/without positive culture
Do Blood c/s if child not stable for an LP* (see below for contra-indications)

2. ORGANISM COMMONLY CAUSING BACTERIAL MENINGITIS


Neonatal period
E. coli and other Gram-negative organisms
Listeria monocytogenes, (rarely seen at KATH)
Group B streptococcus (rarely seen at KATH)
1 month - 6 years

>6 years

3. ASSESSMENT
History
Fever
Headache
Photophobia
Poor feeding / vomiting
Irritability
Hypotonia
Drowsiness
Coma

Neisseria meningitides (meningococcus)


Streptococcus pneumoniae(pneumococcus)
Haemophilus influenza
Neisseria meningitides (meningococcus)
Streptococcus pneumoniae(pneumococcus)

Examination
Investigation
Fever
Blood glucose
Purpuric rash
FBC + MPs
Photophobia
CSF c/s, Protein & glucose
Convulsion
Blood c/s
Neck stiffness/bulging fontanelle
Kernig / Brudzinski sign +ve
Irritable child
Coma / Drowsy

*Contra-indications for lumbar puncture


I.
Focal neurological signs
II.

Clinical signs of raised ICP (apart from bulging fontanelle)

III.

Coagulopathy

IV.

Local infection at site of needle insertion

V.

Cardiopulmonary

VI.

If it causes undue delay in the administration of antibiotics (+ve

instability

culture still possible within 2hrs of antibiotic administration)

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4. TREATMENT / MANAGEMENT PRIORITIES:


Antibiotics
<1 month
Penicillin + Gentamycin
(Second line: 3rd generation cephalosporin e.g. cefotaxime or ceftriaxone)
>3 months

Penicillin G & Chloramphenicol


(Second line: 3rd generation cephalosporin e.g. certriaxone or cefotaxime)

Duration,
Pneumococcus
Meningococcus
Haemophilus influenzae
Other Gram-negative organisms

~10- 14days
~5 - 7days
~7 -10days
~ >21days

Steroids
>1 month 6 years old child, give Dexamethasone @ 0.6/kg/day in 3-4 divided doses (or
0.4mg/kg/dose Q12h) for 2-4 days.
Start as soon as possible, preferable before 1st dose of antibiotics.
Fluids

If in shock, resuscitate with 0.9% Normal saline or Ringers Lactate or Colloids.


Correct / prevent hypoglycaemia.
Restrict fluid to 70% maintenance, but not at the expense of adequate intravascular volume.
DO NOT give fluids containing no sodium to patients with meningitis unless you are just keeping the
line open.

Cerebral monitoring
Stop / control seizures with anticonvulsant (fever with tepid sponge & antipyretic)
Monitor coma score, brainstem function for herniation, BP, HR, RR, Temp.(see neurology section)
Public health notification & antibiotic prophylaxis of contacts
Meningococcus:
Postexposure chemoprophylaxis





Rifampicin:
o <1mth old 10mg/kg/day in 2 divided doses for 2 days
o >1mth old 20mg/kg/day in 2divided doses for 2 days
(max.1200mg/day)
Ceftriaxone:
o 50-75mg/kg stat IM/IV
Ciprofloxacin:
o 500-750mg stat for non-pregnant adult (i.e. >12yrs)
Exposed personso household, child care, and nursery school contacts
o Potential contact with oral secretions of infected patient.

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Haemophilus influenzae:
Postexposure chemoprophylaxis





Rifampicin:
o <1mth old 10mg/kg PO daily for 4 days
o >1mth old 20mg/kg PO daily for 4 days (max.600mg/day)
Ceftriaxone:
o 50-75mg/kg stat IM/IV
Exposed persons
o <4yrs-household, child care, and nursery school contacts
o Potential contact with oral secretions of infected patient.

5. COMPLICATIONS
Local vasculitis
i)
ii)
Local cerebral infarction
Subdural effusion
iii)
Hydrocephalus
iv)
v)
Cerebral abscess

6. DRUG DOSAGES FOR BACTERIAL MENINGITIS BEYOND THE NEONATAL PERIOD


DRUG
DOSAGE
Penicillin G

0.5 - 0.6mu /kg/day in 4-6 divided doses

Ampicillin

150 -200mg/kg/day in 4 divided doses

Chloramphenicol

100mg/kg/day in 4 divided doses

Cefotaxime

150-200mg/kg/day in 3-4divided doses

Ceftriaxone

80 - 100mg/kg/day daily

Ciprofloxacin

30mg/kg/day in 2 divided doses

Cefuroxime

200 -240mg/kg/day in 3-4 divided doses

Meropenem

40mg/kg/dose Q8hrly

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5.2.0 SEVERE MALARIA


DEFINITION
Plasmodium falciparum malaria infection which is of immediate threat to life, it is a medical
emergency, and may present with;
Confusion
Prostration
Coma
Convulsions
Severe anaemia
Acute renal failure
Hypoglycaemia
Metabolic acidosis
Acute Respiratory Distress Syndrome (non-cardiogenic pulmonary oedema)
Respiratory distress
Circulatory collapse, shock (algid malaria)
Spontaneous bleeding and coagulopathy
Hyperpyrexia
Hepatic dysfunction (Jaundice)
Hyperparasitaemia
Malarial haemoglobinuria
5.2.1 CEREBRAL MALARIA

1. DIAGNOSIS:

Falciparum malaria evidence


Unarousable coma. Blantyre coma score 2/5
Rule out other causes of encephalopathy

2. ASSESSMENT
Airway (maintain patent) or protect airway if actively convulsing
Breathing, rate and depth of respiration
Circulation, pulse rate and blood pressure
Temperature
Level of consciousness (Blantyre coma score)
State of hydration
Presence of aneamia (palmer / conjunctival pallor) or bleeding
Investigation
a. Fingerprick blood glucose
b. Thick and thin films for malaria parasite
c. Haematocrit (PCV), lumbar puncture.
d. FBC (leucocytosis is not unusual in severe disease and does not necessarily imply an
associated bacterial infection.)
e. Blood culture in suspected septicaemia (e.g. algid malaria)
Assess deepness of coma with a coma scale familiar with other health staff (see examples in neurology
section)

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MANAGEMENT OF SEVERE MALARIA


Maintain airway and oxygenation supplementary oxygen to keep SaO2>92%
Maintain adequate hydration +Treat/Correct shock if present
Exclude/ treat hypoglycaemia.
Start 5 - 10% Dextrose containing fluid till able to tolerate enteric feeding.
Start appropriate anti malarial immediately, preferable parenteral.
Treat convulsions with anticonvulsants e.g. benzodiazepam, phenobarbitone, phenytoin
Exclude other treatable causes of coma.
Record fluid intake & output.
Haemotransfuse screened fresh whole blood or packed cells for severe anaemia.
Antibiotics for suspect Gram-negative septicaemia in children with shock, (i.e. algid malaria).
Monitor & record vital signs brain stem function and level of consciousness.
Manage complications appropriately

4. ANTIMALARIAL
A. QUININE (IM)
Indications: Cerebral malaria, Malaria with altered sensorium, other forms of severe malaria
Give 20mg dichloride salt/kg (loading dose) then 10mg salt /kg Q8hrly for 24-48hrs, then Q12hrly
until the Patient can swallow, then oral quinine @10mg salt /kg Q8hrly to completed a 7-day
course of treatment or give complete course of an effective ACT.
Give IM quinine in the anterior/anterior-lateral thigh (not in the buttocks).
The loading dose of quinine should be divided between 2 sites, half the dose in each anterior
/anterior-lateral thigh
Dilute quinine in normal saline to a concentration of 60 - 100mg salt /ml.
May give Quinine as IV infusion in Dextrose @ < 3-5mg/kg/hr; Same dose as above
B. ARTERMISININ OR ARTERSUNATE INJECTION/SUPPOSITORY
Injection Artesunate (IM/IV) 2.4mg/kg /dose
Injection Artemeter (IM) 3.2mg/kg/dose
Rectal Artesunate (PR) 5mg/kg/dose
Dihydroartermisinin (IM/PR) 2mg/kg/dose
Give on 0hr, 12hr, 24hr then daily (i.e. Q12h for 24hrs, then Q24h)
a. till patient can take oral then give a complete course of oral ACT
b. for 7 completed days
C. ARTERMISININ COMBINATION THERAPY (ACT)
Indication: for uncomplicated malaria, continuation treatment after parenteral quinine.
a. Amodiaquine / Artesunate(PO)
Oral Amodiaquine at 8-10mg/kg/day for 3 days PLUS Artersunate at 4-5mg/kg/day for 3days
b. Artemether/Lumefantrine 20/120mg (e.g. Coartem)
Dose schedule: 0hr repeat dose after 8hrs then Q12h for 2days
5 -15kg @ I tablet/dose
15-25kg @ 2 tablets/dose
25-35kg @ 3 tablets/dose
>35kg @ 4 tablets/dose
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5.2.2 MALARIA TREATMENT SUMMARY IN MALARIA ENDEMIC REGION

Yes
Coma?
No
Blood slide for
malaria parasite
positive?

No

Look for
another cause
of illness

Yes
Yes

Prostration /
Severe lethargy?
No
Lower Chest
Indrawing or
acidotic breathing

No
Hb < 5 g/dl, PCV <
15% (or severe
pallor if Hb not
possible)

Yes

No
Hb 510 g/dl, PCV
1630% or pallor

Treat with IVI or IM Quinine:


1) Loading dose 20mg/kg IM or over 3-4
hours IVI, then
2) 10mg/kg IM or IVI over 2-3 hours every 8
hours.*
3) Give 4-5mls/kg 10% glucose if
hypoglycaemic (suspected) as bolus.
4) If in coma give 3mls/kg/hr maintenance
fluids IV or NG.
5) If weak pulse AND capillary refill >3secs
give 20mls/kg Ringers or Saline bolus, use
whole blood if Hb <6g/dl.

Yes

Urgently transfuse minimum


20mls/kg whole blood or 1020mls/kg packed Red Blood
Cells (pRBCs) over 4 hours

Treat with oral iron for 4 weeks. If respiratory distress


develops and Hb < 5g/dl (or severe pallor if Hb measurement
not possible) transfuse urgently.

Yes

No
Received AQ
within 4 weeks?

No

Treat with oral AQ and


observe progress

Yes
Received AL
within 4 weeks?

No

Treat with oral AL and


observe progress

Yes
Treat with oral QN or other recommended ACT
and observe progress
*Must complete 3 doses of QN before finishing treatment with oral ACT [AL/AQ] or QN.
If treated with AQ/AL [ACT] within the last 4wks complete 7 days of QN by mouth or complete

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5.3.0 TETANUS
Definition
Acute spastic paralytic illness caused by tetanospasmin, an exotoxin (neurotoxin) produced by clostridium
tetani
Clinical features
Incubation period typically 2 14 days, but may be as long as several months after the injury, often
forgotten.
May present as
o localized tetanus or
o generalized tetanus.
Clinical features
o Main features are trismus other rigid muscles (spasms) with clear sensorium.
o Other features are fever, tachycardia
Localized tetanus
Painful spasm of the muscles adjacent to the wound site. This may precede generalized tetanus.
I.
Cephalic tetanus:Involves the bulbular musculature on account of wounds on the head, nostrils, face or chronic otitis
media and may present as
o retracted eyelid,
o deviated gaze,
o trismus,
o spastic paralysis of the tongue / pharyngeal musculature
Generalized tetanus
II.
Disturbance by sight, sound or touch may trigger sudden, severe tonic contraction of the muscles
with fist clenching, flexion and adduction of the arms hyperextension of the legs.
Differential Diagnosis
Meningitis
Dental or Para/Retro-pharyngeal abscess
Rabies
Acute encephalitis involving the brain stem
Management
Eradication of Clostridium tetani
o Clean wounds, debride as needed
o Antibiotics for 10 14 days
Penicillin @ 0.2 - 0.3mu/kg/day 6hrly Metronidazole @ 30mg/kg/day 8hrly x 5days
Or Erythromycin, tetracycline (children 8yrs) for penicillin allergy

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Immune therapy
Optimal doses not determined. Adults and children receive the same dose
a.
o
o
b.

Usual doses given after a test dose (for ATS), are either:
Human tetanus Immune globulin (TIG) @ 5,000U 6,000U intramuscularly OR
Anti tetanus Serum (ATS) @ 50,000U 100,000U. Give half IV and other half IM
Active immunization with 3 doses of Tetanus toxoid (Td) 0.5ml.
Separate syringes and separate site from ATS or TIG!
Give 2nd dose 4-6weeks from 1st dose and 3rd dose 6-12 months from the 2nd dose

Control of spasms (Given in alternate regimens)


o Diazepam 0.05-0.2mg/kg SLOW IV or 0.3-0.5mg /kg PR (max. 10mg/dose) Q 4-6hrly
o Phenobarbitone 5 - 10mg/kg/8-12hrly IM
o Chlorpromazine 0.5mg/kg/ 6-8hrly IM
 May combine any two of the above or intravenous Midazolam infusion
 Caution: Beware and monitor for possible respiratory distress
Consider paralysing and mechanical ventilation if the above fail to control spasms

Supportive care
Nurse meticulously in a quiet, secluded setting

Complications
Aspiration
Apnea
Intramuscular haematoma
Soft tissue injury
Fracture
Rhbdomyolsis  Myoglobinuria  Renal failure
Cardiac arrhythmias
Serum sickness
Labile temperature
Unstable blood pressure
Prevention
Injury prevention
Early and effective wound management(i.e. Cleaning and removal of foreign bodies)
Use of sterile equipment or sharps
Adequate tetanus prophylaxis for injuries
Adequate infant and pregnant women immunization (i.e. Universal immunization)
Adequate immunization for nursing mothers of children with neonatal tetanus

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6.0 MALNUTRITION
6.1.0 DEFINITION AND GENERAL GUIDELINES
DEFINITION:
Severe malnutrition (multiple nutrient deficiencies) is characterised by oedema or wasting, usually with
anorexia and infection
Severe Acute Malnutrition (SAM) is defined as weight-for-height of < - 3 SD/ 70% Expected Weight OR
bilateral oedema in the presence of other signs of malnutrition/absence of other causes of oedema .

Two clinical pictures are seen with much overlap (marasmus and kwashiorkor)
Both have severe hypoproteinaemia, hypokalaemia, hypomagnesaemia and hypogylycaemia, and
anaemia

CLASSIFICATION OF MALNUTRITION

Moderate malnutrition
Oedema
Weight for height
Height for age

Severe malnutrition

No

Yes (kwashiorkor)

<-2 SD

<-3 SD (marasmus)

<-2SD (moderate stunting)

<-3SD (severe stunting)

CLINICAL MANAGEMENT

All cases should have the PEM data (enclosed in patients folder) filled in whole by the attending
doctor (i.e. the admission data, laboratory data, and discharge/demise data).
Weight and Height should always be re-checked on admission using the appropriate height
measuring device and Weight-for Height (Z-score) computed.
Body weight should be measured and recorded every other day.
The under-listed investigations should be done ROUTINELY for all cases:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.

Blood
Full Blood Count (haematology)
Culture & Sensitivity
Urine
Dipstick + microscopy
Culture & Sensitivity
Stool R/E
Chest X-ray (with Radiologists report)
Provider initiated Counseling and Testing for HIV*
Gastric Lavage (Discuss with senior resident/specialist)
LFT
Other Investigations as may be necessary

Acute complications must ALWAYS be looked for and treated appropriately (see overleaf)

*Counseling and testing for HIV should only be done when the patient has been well stabilized and parents
are in the best psychological state of the mind to undergo counseling. Results of the test must remain
PRIVATE AND CONFIDENTIAL and should only be released to the head nutritionist and/or consultant.
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6.1.1 TREATMENT OF SPECIFIC PROBLEMS OF THE SEVERELY MALNOURISHED


ALWAYS LOOK FOR THE FOLLOWING COMPLICATIONS ON ADMISSION AND TREAT APPROPRIATELY:
HYPOGLYCAEMIA (BM stick RBS < 3 mmol/L OR Bedside glucometer RBS < 2.5mmol/L)
Treatment: 5mls/Kg of 10% Dextrose given IV, PO, or NG tube OR 1 teaspoonful of sugar in 50mls of
water given orally or per N/G tube.
This should be followed with F-75 feeds q30 mins for the next 2 hours.
Note: IV dextrose maintenance SHOULD NEVER be set up even when patient is in shock (see shock
management below).

HYPOTHERMIA (Axillary temp < 350C or rectal 35.50C)


Treatment:
Apply Kangaroo method (if appropriate). Wrap in heavy blanket.
Prevent further heat loss.
DIARRHOEA and/or VOMITING (inquire from history)
Dehydration cannot be assessed accurately in the severely malnourished.
It should only be assumed if diarrhea and/or vomiting is present.
Treatment: Give resomal 5mls/Kg q30 mins for the next 2 hours.
Then alternate resomal (5-10mls/Kg) with F-75 every hour for next 10 hours.
SHOCK -defined by the following signs:
o lethargy or unconsciousness
o cold extremities
Plus one or more of the following:

o CRT >3secs
o Fast thready pulse
Treatment of Shock in the Malnourished:
a. Give O2, correct hypoglycaemia with 10% dextrose IV bolus (5mls/Kg), if present or suspected.
b. Then administer either one of the following IV Fluids at 15mls/kg/hour:

o strength Darrows with 5% dextrose


o R/Lactate with 10 mmol KCL per 500ml R/Lactate in 5 % dextrose
i. Monitor HR and RR every 15 mins.
ii. If the pulse and respiratory rates decrease, then patient is improving in which case
IV Fluid should be repeated (same dose, same rate) one more time.
iii. Otherwise stop IV Fluid and consider possible heart failure (IV Fluid induced).

PURULENT EYE DISCHARGE and/or CORNEAL CLOUDING/ULCERATION


Treatment: Initiate Vit A therapy immediately.
o Discharging eyes should be treated with topical antibiotics (ciprofloxacin,tetracycline,
chloramphenicol, or gentamycin) whilst corneal clouding/ulceration should be treated with
Gutt Atropine and the eyes covered with saline-soaked gauze and then bandaged.
Ophthalmologist consult may be necessary.

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VERY SEVERE ANAEMIA (PCV <12% or Hb < 4g/dl)


Treatment:
Haemotransfuse whole blood / Packed RBCs 7 - 10 mls/kg over 3-4 hours with IV Lasix 1mg/Kg
SEVERE DERMATOSIS -fissured/cracked skin or raw/denuded skin with plasma oozing
Treatment:
Bath in 1% KMO4 solution or apply GV paint. Zinc Oxide ointment can be applied to flaked/denuded
perineal areas.
ANY SPECIFIC INFECTION IDENTIFIED:
Treat according to existing protocol.

6.1.2 ROUTINE TREATMENT FOR THE MALNOURISHED


OFFER THE FOLLOWING TREATMENT AS ROUTINE TO ALL PATIENTS:
ANTIBIOTICS (IV/IM Gentamicin and/or Ampicillin /Cefuroxime/ Flucloxacillin if any of the above
complications is present on admission. Otherwise oral amoxicillin)
INTRODUCE F-75 cautiously according to body weight (see F-75 feeding chart)
Folic acid supplementation
Iron-free Multivitamin supplementation
Introduce F-100 feeds only when patient shows signs of transition
Signs of transition: good appetite (completes most of F-75 feeds), cheerful looking, smiles.
Give Iron syrup (3mg/Kg/day) once patient is gaining weight (usually after transition onto F-100)
Introduce stimulating play activities during the rehabilitation phase
Weigh patient every other day.
Prepare patient for discharge by counseling on appropriate home feeding using home-based food
Discharge patient only when weight-for-height score is -1 SD (or Gain 15% of admission weight)
Book patient for follow-up visit, and if possible arrange for home follow up

6.1.3 IMPORTANT THINGS NOT TO DO

Do not give IV Fluid to treat dehydration unless patient is in shock


Do not transfuse patient if PCV is > 12% (Hb > 4g/dl) unless s/he is in respiratory distress
Never transfuse blood volume more than 10mls/Kg and never faster than 3 hours
Never place patient close to opened window or under fan
Never leave windows opened at night (caution- hypothermia)
Never omit night feeds
Never forget to chart all feeds, medications, and comments/remarks
Never forget to fill in malnutrition data

NOTE: A check list of all the above activities should be completed for each patient and filed in patients
folder.

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6.1.4 SUMMARY OF WHO RECOMMENDATION FOR DIAGNOSIS AND


MANAGEMENT OF SEREVE ACUTE MALNUTRITION (SAM) IN CHILDREN
Diagnostic criteria for SAM in children aged 6 60 months

1 Based on WHO Standards


2,3 Independent indicators of SAM that require urgent action

Severe Acute Malnutrition (SAM) management

*Child eats at least 75% of their calculated RUTF ration for the day

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6.1.5 GUIDANCE TABLE TO IDENTIFY THE TARGET WEIGHT FOR DISCHARGE

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7.0 NEONATAL DISORDERS


7.1.0 INTRODUCTION
Birth asphyxia and neonatal seizures are among the most common problems encountered among neonates
in the Komfo Anokye Teaching Hospital.
Approximately 1 in 3 babies seen at the MBU may present with either condition or both.

7.1.1 NEONATAL RESUSCITATION


RISK FACTORS ASSOCIATED WITH THE NEED FOR RESUSCITATION

Antepartum factors
o Diminished fetal activity
o Age <16 or >35 years
o No prenatal/antenatal care
o Size-dates discrepancy
o Post-term gestation
o Multiple gestation
o Pregnancy-induced hypertension
o Chronic hypertension
o Drug therapy: adrenergic blockers
o Antepartum haemorrhage (APH)

Intrapartum factors
o Fetal bradycardia / Fetal distress
o Emergency C/S
o Forceps / Vacuum assisted delivery
o Breech or abnormal presentation
o Use of general anaesthesia
o Premature labour
o Precipitous labour
o Prolonged rupture of membranes ( > 18
hours before delivery)

58

o
o
o
o
o
o
o
o
o
o

Maternal infection
Polyhydramnios
Oligohydramnios
Previous fetal or neonatal death
Anaemia or isoimmunisation
Magnesium
Maternal substance abuse
Fetal malformation
Maternal diabetes
Maternal cardiac, renal, pulmonary,
thyroid or neurologic disease

o
o
o
o
o
o
o
o

Prolonged labour > 24 hours


Prolapsed cord
Prolonged second stage of labour >2hours
Non-reassuring heart rate patterns
Uterine tetany
Meconium-stained amniotic fluid
Chorioamnionitis
Narcotics administered to mother within 4
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A B Cs of RESUSCITATION

Airway





Position and clear 30 seconds

Place under the radiant heater


Position by slightly extending the neck sniffing position
Place a rolled cloth/towel under the shoulders (if available)
Suction mouth, then nose

Breathing









- Stimulate to breath 30 seconds

Dry baby, change wet linen


Reposition the head,
Other ways to stimulate the baby are;
Slapping or flicking the soles of the feet or
Gently rub the back, trunk or extremities
Give oxygen as necessary
If not breathing, give positive pressure ventilation (PPV) with bag and mask (page 4,5)
Oxygen saturation

Circulation Assess heart rate and colour 30 seconds








Drugs




Blue baby/cyanosis, give oxygen


Acrocyanosis-( pink centrally but blue extremities), if breathing and SpO2 88%, - No need
for oxygen
HR <100bpm, give PPV
HR <60bpm, give PPV and chest compressions (page 6,7)
Oxygen saturation

- e.g. Adrenaline

Cardiac stimulant
Inotropic effect, increases the strength and rate of cardiac contractions
Peripheral vasoconstriction, increasing blood flow to the heart and brain

Key point!
Evaluation is based primarily on the following three signs:

1. Respirations increase in rate and depth after stimulation, good chest rise
2. Heart rate should be > 100bpm
3. Colour pink all over

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RESUSCITATION ALGORITHM

Birth

Clear of meconium ?
Breathing or Crying?
Good muscle tone?
Colour pink?
Term gestation

Provide warmth
Positive; clear airway*
( as necessary)

Dry, stimulate, reposition


Give O2 (as necessary)

Evaluate respirations,
heart rate, and colour

Provide positive
pressure ventilation*

Provide positive pressure ventilation*


Administer chest compression

Supportive
care

Ongoing care

Administer
epinephrin
e

Recheck effectiveness of
Ventilation
Chest compression
Endotracheal intubation
Consider possibility of

Consider:

Depressed respiratory
neuromuscular drive
Airway malformations
Lung problems, such as
Pneumothorax

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BAG-AND-MASK VENTILATION

What do you need to check before giving bag and mask ventilation?






Select the appropriate-sized mask, 750ml bag


Be sure there is a clear airway
Position the babys head
Position yourself at the side or head of the baby

How do you position the bag and mask on the face?


1. The mask should be placed on the face so that it covers the nose and mouth, and the tip of the
chin rests within the rim of the mask.
2. Do not jam the mask down on the face; can bruise the face
3. Do not allow your fingers or parts of your hand to rest on the babys eyes.
How do you know how hard to squeeze the bag?
1. A noticeable rise and fall of chest is by far the best indication that the mask is sealed and the lungs
are being inflated.
2. **Premature babies have even smaller breath sizes, but may also have stiffer lungs requiring higher
inflation pressures to deliver smaller volumes.
How often should you squeeze the bag?
1. Breath sounds should be delivered at a rate of 40 to 60 bpm
2. To help maintain this rate, try saying to yourself as you ventilate the newborn:
Breathe.TwoThree..Breathe..TwoThreeBreathe
(squeeze)

(release)

(squeeze)

(release)

(squeeze)

What do you do if the chest is not rising with each squeeze of the bag?
CONDITION
1. Inadequate seal
2. Blocked airway

3. Not enough pressure

ACTIONS
Reapply mask to face
Reposition the head
Check for secretions; suction if present
Ventilate with newborns mouth slightly open
Increase pressure until there is an easy rise and fall of the chest
Consider endotracheal intubation

How do you know if the baby is improving and that you can stop positive-pressure ventilation?
Improvement is indicated by three signs:
1. Increasing heart rate
2. Improving colour
3. Spontaneous breathing

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Notes:





Newborns requiring bag-and-mask ventilation for longer than several minutes, should have
an orogastric tube inserted, suction gastric contents, then leave it in place because:
A stomach distended with gas puts pressure on the diaphragm, preventing full expansion of
the lungs.
Gas in the stomach may cause regurgitation of gastric contents, which may then be aspirated
during bag-and-mask ventilation.

What do you do if the baby is not improving?












Is chest movement adequate?


Is the face-mask seal tight?
Is the airway blocked because of improper head position or secretions in the nose, mouth, or
pharynx?
Is the bag working properly?
Is air in the stomach interfering with chest expansion?
Is 100% oxygen being administered?
Is the oxygen tubing attached to the bag and to the oxygen source?
Is gas flowing through the flow meter?
If you have checked all these factors and chest expansion is still not satisfactory, or you
dont hear good breath sounds bilaterally, then insert an endotracheal tube at this time.
Complications like pneumothorax may have occurred.

*NOTE*: Recent studies have suggested that babies can be successfully resuscitated with room air (21%
oxygen). However, the recommendation is for 100% oxygen when it is available.

CHEST COMPRESSIONS

What are chest compressions?


1. Sometimes referred to as external cardiac massage
2. Compress the heart against the spine
3. Increase the intrathoracic pressure
4. Circulate blood to the vital organs of the body
*NOTE*: The heart lies in the chest between the lower third of the sternum and the spine.
How do you position your hands on the chest to begin chest compressions?
1. Thumb technique
The two thumbs are used to depress the sternum, while the hands encircle the torso and the fingers
support the spine.
2. Two-finger technique
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The tips of the middle finger and either the index finger or ring finger of one hand are used to compress the
sternum.
The other hand is used to support the babys back, unless the baby is on a very firm surface.
Where on the chest do you position your thumbs and fingers?
The lower third of the sternum, which lies between the xyphoid and a line drawn between the nipples.
When compressing the chest, only the two fingertips should rest on the chest.
With the thumb technique, you should apply pressure vertically to compress the heart.
How much pressure should you use to compress the chest?
Depress the sternum to a depth of approximately one-third of the anterior-posterior diameter of the chest,
then release the pressure to allow the heart to refill.
Do not lift your thumbs or fingers off the chest between compressions.
Provide enough pressure for compressions without damaging underlying organs.
How often do you compress the chest and coordinate with ventilation?
1. Three compressions to One ventilation
One-and-Two-and- Three-and-Breathe-and-One-and-

2. It should come to at least 30 breaths and 90 compressions per minute.


When do you stop chest compressions?
If the heart rate >60bpm, then discontinue chest compressions but continue positive-pressure ventilation,
at a rate of 40 to 60bpm.
What do you do if the baby is not improving?
You should continue to ask yourself the following questions-






Is chest movement adequate? (Have you considered or performed endotracheal intubation)


Is 100% oxygen being given?
Is the depth of chest compression approximately one-third of the diameter of the chest?
Are the chest compressions and ventilation being well coordinated?

If the heart rate remains <60bpm, then give Adrenaline medications; page
ENDOTRACHEAL INTUBATION

When is endotracheal intubation required?


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If there is meconium and the baby is not vigorous depressed respirations, muscle tone, or heart rate, you
will need to intubate the trachea as the very first step, before any other resuscitation measures are started.
If positive-pressure ventilation by bag and mask is not resulting in good chest rise
If the need for positive-pressure ventilation lasts beyond a few minutes, you may decide to intubate simply
to improve the efficacy and ease of assisted ventilation.
If chest compressions are necessary, intubating may facilitate coordination of chest compressions and
ventilation
Can be used as a route to administer Adrenaline
How do you prepare the endotracheal tube for use?
Select the appropriate-sized tube.
Tube Size (mm)
(inside diameter)

Weight

Gestational Age

(g)

(wks)

2.5

Below 1,000

Below 28

3.0

1,000 2,000

28 34

3.5

2,000 3,000

34 38

Above 3,000

Above 38

3.5 4.0

Ideal tube length 13 15cm


How do you prepare the laryngoscope and additional supplies?
 Select blade and attach to handle
 No. 0 for preterm newborns
 No. 1 for term newborns
 Check light
 Prepare suction equipment
 Prepare resuscitation bag and mask
 Turn on oxygen
 Get stethoscope
 Cut tape or prepare stabilizer
How should you position the newborn to make intubation easiest?
Use the same position as for bag-and-mask ventilation i.e. the sniffing position
How do you hold the laryngoscope?

First turn on the laryngoscope light


Hold the laryngoscope in your left hand, between your thumb and first two or three fingers,
with the blade pointing away from you.

How do you visualize the glottis and insert the tube?


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1. Stabilize the babies head with your right hand sniffing position.
( Free-flow oxygen should be delivered throughout the procedure )
2. Slide the laryngoscope blade over the right side of the tongue, pushing the tongue to the left
side of the mouth
3. Advance the blade until the tip lies in the vallecula, just beyond the base of the tongue. You
may need to use your right index finger to open the babies mouth.
4. Lift the blade slightly, thus lifting the tongue out of the way to expose the pharyngeal area.
5. Do not elevate the tip of the blade by using a rocking motion and pulling the handle toward
you.
6. Look for landmarks: the epiglottis at the top, the glottic opening below, and the vocal cords
appearing as vertical stripes on each side of the glottis or as an inverted letter V
7. Insert the tube with your right hand
8. The vocal cord guide the black marking close to the end of the tube, should be at the level
of the cords. * If the cords are together wait for them to open*
9. Stabilize the tube with one hand, and remove the laryngoscope with the other.
How do you check to be sure that the tube is in the trachea?

If the tube is positioned correctly, you should observe:


A rise in the chest with each breath
Breath sounds over both lung fields, but decreased or absent over the stomach
No gastric distension with ventilation
Vapour condensing on the inside of the tube during exhalation

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7.2.0 BIRTH ASPHYXIA


Clinical Definition/Criteria:
Age:
By definition, this disease is seen in the newborn period.
Most neonates are term at birth.
In most cases, the disease manifests at birth or within a few hours after birth.
History:

Persistence of an Apgar score of 0-3 for longer than 5 minutes


Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)
Multiple organ involvement (eg, of the kidney, lungs, liver, heart, intestines)
Maternal History e.g. Prolonged labour, C/S , Meconium stained liquor,etc
Profound metabolic or mixed acidemia (pH <7.00) in an umbilical artery blood sample, if
obtained

Physical examination:
Clinical manifestations and course vary depending on Hypoxic Ischaemic Encephalopathy (HIE)
severity.
Mild HIE / Aspyhxia
Hyperalert :- appearance of hunger, yet not feeding well; together with a wide-eyed gaze, but
failure to fixate.
Irritability, or excessive crying or sleepiness, may be observed.
By 3-4 days of life, the CNS examination findings become normal.

Moderate HIE / Asphyxia


The infant is lethargic, with significant hypotonia and diminished deep tendon reflexes.
Seizures may occur within the first 24 hours of life.
Full recovery within 1-2 weeks is possible and is associated with a better long-term outcome.
An initial period of well-being may be followed by sudden deterioration, suggesting reperfusion
injury; during this period, seizure intensity might increase.
Severe HIE / Asphyxia
Stupor or coma is typical. The infant may not respond to any physical stimulus.
Breathing may be irregular, and the infant often requires ventilatory support.
Generalized hypotonia and depressed deep tendon reflexes are common.
Seizures occur early and often and may be initially resistant to conventional treatments.
The seizures are usually generalized, and their frequency may increase during the 2-3 days after
onset, correlating with the phase of reperfusion injury.
The fontanelle may bulge, suggesting increasing cerebral edema.

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Infants who survive severe HIE


The level of alertness improves by days 4-5 of life.
Hypotonia and feeding difficulties persist, requiring tube feeding for weeks to months

Lab investigations:
No specific test excludes or confirms a diagnosis of HIE.
The diagnosis is based on the history and physical examination.
Choice of tests depends on the evolution of symptoms.
As with any other disease, test results should be interpreted in conjunction with clinical history and
the findings of physical examination.
Management of Birth Asphyxia:
Effective Resuscitation
General supportive care
o Keep warm:- under the radiant heater or in the incubator
o Oxygen:- if blue or Oxygen saturation < 88%
o Correct hypoglycaemia (i.e. RBS 2.2mmol/L ) by giving 5ml/kg body weight of 10% Dextrose
IV, continued with maintenance IV 10% Dextrose
o Feeding / Fluid Therapy - depending on gestational age, weight, and severity of asphyxia
Mild HIE/Asphyxia:
- Can start with NG tube or Cup feeds (e.g. EBM), based on weight for the 1st 24hours, then
continue with breastfeeding as soon as baby is able to suck.
Moderate and Severe Asphyxia/HIE:
- In the first 2-3days of life, restrict intravenous fluids to two thirds of the daily requirement
for gestational age/weight.
- Restrict to nothing by mouth (NPO) during the first 3days of life or until the general level of
alertness and consciousness improves.
- When infants begin to improve, urinary output increases, and fluid administration must be
adjusted to daily maintenance.
- If there are no seizures, the baby can then be started on NG tube feeds 2-3hrly, and if
tolerating feeds well, can later be put on cup feeds EBM depending on the weight.

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7.2.1 CLINICAL STAGES OF BIRTH ASPHYXIA (Perinatal Hypoxic Ischemic Encephalopathy)

Stage 1
Mild
Level of
Consciousness

Hyperalert

Stage 2
Moderate

Stage 3
Severe

Lethargic or obtunded

Stuporous

Mild hypotonia

Flaccid

Neuromuscular Control
Muscle tone

Normal

Posture

Mild distal
flexion

Strong distal flexion

Intermittent decerebration

Suck

Weak

Weak or absent

Absent

Moro

Strong; low
threshold

Weak; incomplete;
high threshold

Absent

Tendon
reflexes/clonus

Hyperactive

Hyperactive

Absent

Autonomic Function

Generalized
sympathetic

Generalized
parasympathetic

Both systems depressed

Pupils

Mydriasis

Miosis

Unequal; poor light reflex

Heart Rate

Tachycardia

Bradycardia

Variable

Bronchial and Salivary


Secretions

Sparse

Profuse

Variable

Gastrointestinal
Motility

Normal or
decreased

Increased; diarrhea

Variable

Seizures

None

Common; focal or
multifocal

Decerebration

Duration

<24 h

2-14days

Days to weeks

Reflexes

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7.3.0 NEONATAL SEIZURES:


Management of NEONATAL SEIZURES

1.

2.

Stabilize the patient:


 Assess Airway, Breathing & Circulation
 Administer oxygen
 Check blood glucose
 Correct hypoglycaemia if present
 Check temperature, if > 38C, give paracetamol suppository 125mg st.
Begin pharmacotherapy to stop the seizures:
Drugs commonly used in this Unit are: Phenobarbitone, Phenytoin or Midazolam

Phenobarbitone

Pediatric
Dose

15 -20 mg/kg IM, or IV slowly over 10 -15min as loading dose (preferably IM)
In refractory cases: seizures persisting after 30mins, give an additional 5-10 mg/kg IM as
loading dose
Followed by 3-5 mg/kg/d IM divided bid, to begin no earlier than 12-24 h after loading dose;
slow IV push gives most rapid control.
Maximum loading dose - 20mg/kg

Midazolam

Pediatric
Dose

Given as Midazolam infusion


0.15mg/kg loading dose, then 1mcg/kg/min (max. dose 4mcg/kg/min)
Titrate upwards every 5mins till seizure stops.

Phenytoin
Pediatric
Dose

15-20 mg/kg IV over >30 min as loading dose;


Followed by 4-8 mg/kg IV slow push q24h; rate of infusion not to exceed 0.5 mg/kg/min;
Flush IV line with 0.9% NaCl before and after administration

Stop anticonvulsants as early as possible when seizures stop so that you can accurately evaluate childs
level of consciousness.

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7.4.0 ANAEMIA IN THE NEWBORN


Definition
Anaemia is a decreased concentration of haemoglobin and red blood cell mass compared to age
age-matched
controls.
Normal Haemoglogin values in the Newborn

7.4.1 COMMON CAUSES OF ANAEMIA IN THE NEWBORN

1st 24 hours of life









Maternal causes e.g.


g. APH
Fetal causes e.g.
g. Twin
Twin-twin transfusion
Neonatal causes e.g.
g. Haemorrhagic disease of the newborn - early onset (if the mother has
been on drugs like phenytoin or rifampicin)
Cord bleeding
Birth injuries e.g. intracranial
ntracranial haemorrhage
haemorrhage,, subgaleal bleed, massive cephalhaematoma
ABO and Rh incompatibility
G6PD deficiency

1st week of life

Same as 1st 24hours of life plus


o Haemorrhagic disease of the newborn classic type from the 3rd day
o Infection Septicaemia
o DIC

Beyond the 1st week of life


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Haemorrhagic disease of the newborn late onset, usually due to liver disease
G6PD deficiency
Infection eg malaria usually after 4weeks of life, and septicaemia

7.4.2 CLINICAL FEATURES OF ANAEMIA IN THE NEWBORN

Key questions in the history:


Ask about:









Maternal history of bleeding


History of bleeding in other siblings
Home delivery Vit K not given
Vacuum extraction done or failed vacuum
Neonatal jaundice in other siblings
Herbal medication given G6PD deficiency
Presence of fever, etc

Symptoms








Poor feeding
Difficulty in breathing/tachypnoea
Vomiting
Irritability
Lethargy
Failure to gain weight

Signs
















Pallor
Weak pulses
Cold extremities
Decreased capillary refill time
Hypotension
Tachypnoea
Tachycardia
Apnoea
Obvious bleeding eg. From the cord, mouth, nostrils etc
Abdominal distension from intra-abdominal bleeding
Increasing head size, pitting oedema on the forehead and behind the ears - subgaleal bleed
Jaundice
Hepatosplenomegaly
Fever

Investigations







Urgent PCV
Complete blood count, film comment,
Malaria parasites age > 1month
Reticulocyte count
Blood grouping and cross-matching
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If jaundice is present include:-







Grouping and cross-matching against the mothers blood, Rhesus factor


Direct antibody test (Coombs)
Serum bilirubin - SBR
G6PD screen
Blood C/S

7.4.3 MANAGEMENT

FIRST STOP BLEEDING*


o If in shock from blood loss, give 10ml/kg of Normal Saline over 30mins while
arranging for blood, and monitor RR, HR, CRT, peripheries, and passage of urine. If
Normal Saline is not available give Ringers Lactate.

Transfusion guidelines:
WHAT TO GIVE
- Whole blood (Fresh if possible ) or Packed RBCs 20ml/kg/day given over 4hours.
- Whole blood should be given for anaemia due to blood loss, and packed cells for haemolysis.
- In acute haemorrhage, a bolus of whole blood 5ml/kg can be given over 30mins.
- Give I.V. lasix 1mg/kg st, if cause of anaemia is not due to blood loss.
WHEN TO TRANSFUSE
- Do not transfuse for phlebotomy losses alone.
- Do not transfuse for hematocrit alone, unless the hematocrit level is less than 40% in the 1st 24hrs
of life, and 30% within the 1st week of life.
- Transfuse for shock associated with acute blood loss.
- Transfuse (beyond the 1st week of life) for hematocrit levels less than 35% in the following
situations:
Infant with severe pulmonary disease; CHECK oxygen saturation
Infant in whom anemia may be contributing to congestive heart failure
In the following situations, (beyond the 1st week of life) transfuse for a hematocrit level that is 25-30% or
less if:
The patient has significant apnoea and bradycardia
The patient has persistent tachycardia or tachypnoea without other explanation for 24 hours.
Weight gain of patient is deemed unacceptable without other explanation such as known increases
in metabolic demands or known losses in metabolic demands (malabsorption).
The patient is scheduled for surgery; transfuse in consultation with the surgery team.
Iron therapy
Anaemia (refer to drug dosages) without symptoms, clinically stable, give 3-5mg/kg/day. Monitor Hb/PCV
levels
All preterms are to be given iron on discharge mothers should be counseled to start administering iron at
6 weeks/40days
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- Discuss with Resident/Specialist


Indications for Antimalarials:





If malaria parasite is present


After blood transfusion/exchange transfusion
Baby >4wks with fever and anaemia

Antibiotics: where indicated


IM/IV Vitamin K 1-2mg/kg st, then, 1mg/kg after 24hrs if still bleeding. Max. 10mg/day

NOTE: Discuss with Resident/Specialist before any transfusion

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7.5.0 GUIDELINES FOR THE MANAGEMENT OF RESPIRATORY DIFFCULTY IN THE


NEWBORN
SOME COMMON DIFFERENTIALS TO CONSIDER
Dyspnoea from Birth
Meconium aspiration
Birth asphyxia
Transient tachypnoea of the newborn
Congenital pneumonia / infection (2 PROM or Offensive liquor)
Congenital Heart Disease / Heart failure
Hypoglycaemia
Dyspnoea a Few hours to Days after Birth
(Dyspnoea present but missed!)
Respiratory Distress Syndrome
Infection
Anaemia (Bleeding? Haemolysis? Congenital infection)
Fluid overload
Hypoglycaemia
1. The treatment of respiratory distress depends on its severity and cause.
Is it a CARDIAC, RESPIRATORY, INFECTIOUS or METABOLIC problem?
2. The severity is assessed clinically by the Respiratory Distress Score and measured by using the Pulse
Oximeter.
The Respiratory Distress Score
Observations
Respiratory rate/min

0
< 60

60 80

>80

Cyanosis
Grunting
Retractions
Air entry

No
No
None
Good

Cyanosed
Only with stethoscope
Mild to Moderate
Diminished

Cyanosed on oxygen
Loud
Severe
Very poor

Mild respiratory distress score of 1 4


Moderate respiratory distress score of 5 7
Severe respiratory distress score of 8 10
GENERAL MANAGEMENT
1) GIVING OXYGEN
If an infant has Mild respiratory distress ( 4)
a)
b)

Check oxygen saturation


If saturation is 88% do not give oxygen
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If saturation is < 88%, or pulse oximetry is not available, give oxygen by nasal catheter with
a flow of 0.5 to 1L/min
If an infant is cyanosed or has moderate to
c)

Severe respiratory distress (> 4)


a) Check the oxygen saturation
b) Increase oxygen flow till the saturation is 88%
c) Use the oxihood or oxygen face mask, if you have to give an oxygen flow of >2L/min
d) If there is no oxihood or face mask, use double nasal catheters
If apnoeic or RR 20/min, resuscitate with bag and mask, and if HR <60bpm perform chest
compressions.
2) CORRECT HYPOGLYCAEMIA and SHOCK
3) GIVE ANTIBIOTICS
4) FEEDING/IV FLUIDS
a) Amount will depend on the babys weight and age
b) In severe respiratory distress, give IV fluids cautiously (Rule out heart failure!!!)
c) In mild to moderate respiratory distress, give tube feeds (EBM)
d) In mild respiratory distress, mother can breastfeed if there is NO grunting, indrawing or
cyanosis.
e) Feeding tube should be inserted through the mouth rather than the nose
f) Give slow, small and frequent feeds to prevent reflux, distension and aspiration
g) Encourage mother to breastfeed as soon the baby is stable.
5) MONITOR and CHART Respiratory Distress Score, Oxygen Saturation and Capillary Refill Time hourly
and Blood Sugar 3hourly.

7.6.0 FEEDING PROTOCOL FOR BABIES ADMITTED TO THE MOTHER BABY UNIT,
THE IDEAL WHICH WE AIM FOR IS EXCLUSVE BREASTFEEDING FOR EVERY BABY ON THE UNIT. EVERY EFFORT
MUST BE MADE BY ALL STAFF OF THE UNIT TO ACHIEVE THIS, WHERE POSSIBLE.
GENERAL PRINCIPLES TO BE FOLLOWED
1. Artificial feeds are to be handled like drugs. They should only be given when prescribed by the
doctor on duty or with permission from the Nurse in charge. They should only be given for medical
reasons.(see below)
2. A baby who has started breast feeding should never be given artificial feeds until after the mother
has been to feed, if necessary.
3. A baby who is on a functioning IV line with glucose in it should never be given artificial feeds as
there is no immediate risk of hypoglycaemia.
4. Every effort should be made to call mothers OR to take the baby to mother to breastfeed rather
than giving the baby artificial feeds only because the mother is late in coming.
5. Artificial feeds should never be given to babies with birth asphyxia unless there is no functioning IV
line, to reduce the risk of necrotizing enterocolitis.
6. Ward doctors must, as part of daily ward rounds, review the babys feeding chart and as much as
possible find out from the mother independently, how feeding is going, in order to make the
necessary changes in the babys feeding schedule.
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7. It is the duty of all health care staff on the unit to identify mothers with breast feeding problems
and help them to overcome them.
8. In order not to send wrong messages, artificial feeds must not be prepared in full view of the
mothers. All talks to mothers must enforce exclusive breast feeding and where mothers are being
counseled about artificial feeding, this must be done with as much discretion as possible.

EXAMPLES OF COMMON AND ACCEPTABLE MEDICAL REASONS FOR GIVING A BABY ARTIFICIAL FEEDS
1. A baby with a high risk of hypoglycaemia (e.g. a premature baby, a baby of a diabetic mother or a
very growth retarded baby) in whom there is no functioning IV line and in whom the mother is
either not available or in whom it is judged that there is insufficient breast milk to prevent
hypoglycaemia from occurring.
NB A healthy term or near term baby is not at risk of developing hypoglycaemia just because
feeding is delayed for an hour or so HUNGER is not the same as hypoglycaemia.
2. The baby of an HIV positive mother (or any other mother!) who has made an informed choice not to
breast feed. This information must be adequately communicated to the ward staff. (In the case of
the HIV Positive mother, artificial feeds should never be started until the mothers decision on
feeding is known. This to avoid mixing of breast feeding and artificial feed which is believed to carry
a high risk of transmitting HIV to the baby.)
3. Where the mother is dead, or where the mother has abandoned the baby or has a psychiatric
disorder where it is considered that the baby is at risk of being harmed by the mother.

SOME COMMON, NON MEDICAL AND UNACCEPTABLE REASONS FOR GIVING ARTIFICIAL FEEDS e.g.
1. The mother hasnt come. (Send for her!)
2. The baby is too big.
3. The stomach looks flat
4. The baby is crying after being fed.
5. The baby looks hungry.
In all these cases the solution is to give more breast milk and only if this fails should artificial feeds be
considered.
SOME SITUATIONS WHERE ORAL FEEDS SHOULD USUALLY BE WITHHELD
1. Moderate and severe birth asphyxia, (to reduce the risk of Necrotising Enterocolitis).
2. Any neonate who is very ill immediately after birth, or a preterm baby less than 30 weeks. In both
these cases however breast feeding should start as soon as the baby is stable.
3. In suspected intestinal obstruction.
4. In any baby who is going for General Anaesthesia who has been made nil per os.
5. The baby of an HIV positive mother whose feeding choice is not yet known by the ward staff.
6. A baby who on a previous feed has not tolerated oral feeding. (E.g. turned blue or had an apnoeic
attack.)
7. Any neonate with a Respiratory rate >80 breaths per minute or has other signs of severe respiratory
distress.
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8. A baby who is about to have an exchange blood transfusion. (A baby whose bilirubin is being
monitored in whom a decision concerning exchange transfusion has not been taken should be fed.
However feeds should be stopped as soon as the decision to do the procedure is made).
9. A baby who has an umbilical vein catheter should not be fed until the catheter has been removed.
VOLUMES OF FEED TO GIVE
- DAY 1 (i.e. the 1st 24 hour period) - 60ML PER KG PER DAY
- DAY 2 (i.e. the 2nd 24 hour period) - 90ML PER KG PER DAY
- DAY 3 (i.e. the 3rd 24 hour period) - 120 ML PER KG PER DAY
- DAY 4 (i.e. the 4th 24 hour period) - 150 ML PER KG PER DAY
- DAY 5 AND BEYOND:
o For TERM babies, give 150 ML PER KG PER DAY, unless otherwise prescribed.
o For PRETERM AND LOW BIRTH WEIGHT BABIES, GIVE 180 MLS PER KG PER DAY OR MORE IF
THEY WILL TOLERATE IT
 For very small babies, feeds can be given two hourly or even hourly if they cannot tolerate larger
volumes three hourly.
 Where the baby cannot suck, feeds should be given by NG tube or cup depending on the gestational age
and condition of the baby.
 All babies must have a feeding chart which is filled daily.

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7.7.0 GUIDELINES FOR THE MANAGEMENT OF NEONATAL JAUNDICE


Neonatal jaundice is a common condition which doctors are often called upon to manage. Decisions as to
which management option to choose are based on what YOU consider to be the babys risk of developing
kernicterus. This can sometimes be confusing. Below are some guidelines to help you decide how to
manage the baby. In some cases, the decision is straight forward and easy to take. In others, it is not so
simple. Always be prepared to consult when you are not sure what to do.
FIRST DECIDE WHETHER THE JAUNDICED BABY HAS ANY SIGNS OF KERNICTERUS.
Some of the things to look for include the following :
Does he have poor feeding? - Remember to ask whether the baby is feeding AS WELL AS he was the
day before?
Has he become irritable? is he crying more than usual? Is he sleeping poorly? Is he taking longer
than usual to attach to the breast because of fussing or crying?
Has he become lethargic? Is he sleeping more than usual or feeding poorly? Does he have little
movement?
Are there seizures? Are there any abnormal looking movements?
IF THE ANSWER TO ANY OF THESE IS YES, THE BABY MAY BE DEVELOPING KERNICTERUS.
PREPARE HIM FOR AN EXCHANGE TRANSFUSION. (AFTER PERFORMING ALL EMERGENCY PROCEDURES
SUCH AS CORRECTING HYPOGLYCAEMIA, ETC.)

7.7.1 PREPARATION FOR AN EXCHANGE BLOOD TRANSFUSION.

1. While taking blood for culture, G6PD etc, take a specimen from the baby and one from the mother
also for grouping and cross matching. In filling the request form, make sure the lab knows the
request is for an exchange and not a simple transfusion so that you get the right group of blood.
Request for 160mls/kg of blood
2. Set an IV line to rehydrate the baby and treat/prevent hypoglycaemia. Keep the baby nil per os until
after the exchange. If you are conversant with passing an umbilical vein catheter you may go ahead
and do so.
3. Put the baby under phototherapy.
4. Discuss the decision with a senior colleague if ANY doubt exists.
If the answer to all the above questions is no (i.e. you assess the baby as having no signs of kernicterus,)
decide whether there is a risk of this baby developing kernicterus.
Some factors that will put a baby at risk of developing kernicterus include the following:
1. Serum bilirubin of 400/1 in a term baby, or 10 x the gestational age in a preterm baby.
2. A previous history of a jaundiced baby who was hospitalized or severely affected (or even
unexplained neonatal deaths, as the mother may not have observed the jaundice.)
3. Jaundice noticed before the baby was 48 hrs old
4. Age less than 72 hours.
5. Child deeply jaundiced, especially if this involves the whole body including the feet.
6. Prematurity
7. Co-existing illness such as birth asphyxia or injury sepsis, meningitis etc.

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IF THE CHILD HAS ANY OF THESE HE MAY BE AT RISK OF DEVELOPING KERNICTERUS. PREPARE AS IF YOU
ARE GOING TO EXCHANGE HIM AND DISCUSS WITH A SENIOR COLLEAGUE.
If you decide that there is no sign of kernicterus and there is no risk of the baby developing kernicterus, take
all necessary samples to the lab. Usually this will include a blood culture, a full blood count and blood film
for malaria parasites. Always check for G6PD deficiency.
Put the baby under phototherapy and give IV fluids if necessary. Give all other treatments as necessary.
Though many babies admitted for jaundice will need sepsis treatment, this should NOT be a routine.

7.7.2 PERFORMING THE EXCHANGE BLOOD TRANSFUSION (EBT)

You should have observed at least one exchange blood transfusion and should have been supervised to do
at least one, before attempting to do one on your own. You should therefore be familiar with the basic set
of the procedure. Below however are a few points to note.
1. Remember that rehydration and phototherapy may have reduced the bilirubin to a level where EBT
is no longer indicated, especially in borderline cases. As much as possible, especially where the SBR
was not checked in the last hour, recheck before starting.
2. An EBT is a hazardous procedure. Every effort should be made to maintain cleanliness and sterility,
especially when passing the UVC. Once passed, the UVC should be secured to prevent the need for
re- passage and its attendant increased risk of infection and thromboembolism.
3. The baby must be kept warm and carefully monitored during the procedure. If the heart rate or
respiratory rates become deranged, slow down and allow the baby to recover.
4. Aim to do the procedure over two hours to allow the bilirubin in the tissue to equilibrate with that
in the blood.
5. Remember to keep mixing the blood in the bag to prevent anaemia at the end of the exchange. This
is especially important as the adult blood used for the exchange will usually have an Hb well below
the expected value for a baby.
6. At the end of the exchange
a. Remove the UVC slowly.
b. Cover the cord with sterile gauze.
c. Give the baby Vitamin K (treatment dose), and anti malarial and antibiotics if indicated
d. Check the Serum Bilirubin to provide a baseline for subsequent monitoring.
e. Maintain IV dextrose, keep the baby nil per os and continue to monitor until at least two
hour after the exchange.
f. Where the baby is very young (usually < about 4 days), the bilirubin may rise such that
another exchange is needed. Always check again within 6 hours of completing the
procedure. Conversely, there is rarely the need to go on monitoring bilirubin once the
baby is 7 complete days old.

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7.8.0 GUIDELINES TO THE MANAGEMENT OF THE HIV EXPOSED BABY


Diagnosis
The Delivery Head Ticket may have the number 279 written on it, indicating that the mother has the
infection.
Antiretroviral (ARV) prophylaxis
1. Give a single dose of Nevirapine susp. 2mg/kg within 48hrs of delivery PLUS one week course of
a. Syr Zidovudine 4mg/kg bd
PLUS
Syr Lamivudine 2mg/kg bd
BUT
2. If the mother has had less than 4 weeks of ARV prophylaxis, then
a. Give the baby a 6 week course of Zidovudine and Lamivudine.
3. Collect the drugs from the dispensary (FREE).
4. Document all the drugs given in the patients folder or weighing card, and in the 279/PMTCT
records book on the ward.
Feeding options

DO NOT give artificial feeds if the mother has not opted for it.
Find out what feeding option the mother has chosen.
o ? Exclusive breastfeeding
OR
o ? Artificial feeds
If the mother has opted to breastfeed:

Support her
Ask any of the doctors/nurses who have been trained in PMTCT to counsel the mother on
how to minimize risk of infection to the baby.
If the mother has opted not to breastfeed but to give artificial feeds
o Support her
o Ask any of the doctors/nurses trained in PMTCT to counsel mother on AFASS.
If the mother has not made any informed choice or you do not have any information on the
mothers feeding choice, then
o Admit and give IV fluids till the mother has been counseled
o Get in touch with the mother as soon as possible
1. IDENTIFY and TREAT any other problems
o
o

Follow-up

The baby should be seen at the HIV clinic at 6 weeks of age.


If there are any problems before 6 weeks of age, the baby should be brought to the hospital.

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7.9.0 MANAGEMENT OF COMMON BIRTH INJURIES


7.9.1 CEPHALHAEMATOMA

Usually not visible till a few hours after birth. Typically over the parietal bone, (not in the midline!) and does not
cross suture lines. Rarely requires any intervention other than counseling mother to leave alone. Occasionally
may be large or bilateral and may require a blood transfusion. Other than this, should never be the only reason
for admission
7.9.2 SUBGALEAL/SUBAPONEUROTIC HAEMATOMA

Often, (but not always) a history of a difficult vacuum delivery. Presents shortly after birth but may initially be
difficult to differentiate between an early subgaleal bleed and a large caput. Typically extends to cover the whole
scalp and fontanelles may not be palpable as they are covered with haematoma. The distribution of the
haematoma is influenced by gravity and therefore may be masked if baby is lying on his back, for example or may
collect down one side in the parieto-temporal region.

Management
Sometimes associated with shock, hypoglycaemia, birth asphyxia etc, so emergency management aimed at
these.
Check PCV and transfuse accordingly.
If blood transfusion not immediately indicated, monitor PCV AD vital signs every 2 hours. (Remember
that in acute bleeding PCV may not give a true picture of blood loss).
Give therapeutic doses of Vitamin K until bleeding stops (i.e PCV settles).

Give paracetamol for pain relief.


When stable, monitor for jaundice and treat appropriately. Treat associated conditions e.g. sepsis
7.9.3 FRACTURED FEMUR

Typically presents as a baby who does not move one leg and the thigh may be swollen. Confirm by x-ray. There is
often a history of a breech delivery.

Management

Emergency management for asphyxia, shock etc if indicated.


Give paracetamol for pain relief and encourage minimal handling

SPLINTING A FRACTURED FEMUR

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Place the baby on her/his back and place a padded splint under the baby from the waist to below the knee
of the affected leg
Strap the splint to the baby by wrapping an elastic bandage around the waist and from the thigh to below
the knee of the affected leg. Ensure that the umbilicus is not covered by the bandage.
Check the toes daily for three days (this can be done on OPD basis if practical) If the toes become blue
or swollen, remove the bandage and rewrap it more loosely;
If the bandage is rewrapped, observe the toes for blueness or swelling for an additional three days.
Ask the mother return with the baby in 14 days to remove the splint and do check-ray

7.9.4 FRACTURED HUMERUS

Typically presents as a baby who does not move one arm and the upper arm may be swollen. Confirm by x-ray.
There is often a history of a difficult delivery, suggesting shoulder dystocia. If seen very early before swelling is
visible, may be difficult to distinguish from an Obstetric Brachial Plexus Injury or Erbs Palsy.

Emergency management for asphyxia etc if indicated.


Give paracetamol for pain relief and encourage minimal handling

SPLINTING A FRACTURED HUMERUS

Place a layer of cotton wool padding between the affected arm and the chest, from the axilla to the elbow.
Strap the upper arm to the chest using a crepe bandage.

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7.10.0 MANAGEMENT OF NEONATAL TETANUS (NNT)


Suspect tetanus in a previously well neonate with inability to feed and spasms, which are provoked or
aggravated by stimulation. There is often no history of the mother having had anti tetanus immunization
during pregnancy, and there may be a history of poor cord care.
7.10.1 AIMS OF MANAGEMENT

o
o
o
o

RESUSCITATION (Airways, Breathing and Circulation, Treat Hypoglycaemia)


MAXIMUM SPASM CONTROL WITH MINIMUM RESPIRATORY DEPRESSION
IDENTIFICATION AND TREATMENT OF ALL ONGOING INFECTION
MAINTENANCE OF HYDRATION AND NUTRITION

7.10.2 SPECIFIC STEPS TO TAKE

Resuscitate and stabilise, check for and treat hypoglycaemia


Take bloods as for neonatal sepsis and do LP if not contraindicated and if possible give the
following drugs
o Broad spectrum antibiotics as for sepsis/meningitis
o Antitetanus serum 5000 units (or Human tetanus immunoglobulin im, single dose of
500 units preferable if available)
o Chlorpromazine IM/NGT 7.5mg every 8 hrs plus
o Phenobarbitone IM/NGT 30mg stat then 7.5mg every 12 hours
o Diazepam IM/NGT 2mg every 3-6 hrs PRN
Control fever appropriately
Pay attention to keeping the cord clean on a daily basis
Maintain a policy of minimal handling (no bathing!)
Keep well hydrated by NG tube feeding of breast milk, and IV fluids.

Adequate immunization for nursing mothers of children with neonatal tetanus

MONITOR BREATHING AND SPASMS, AND GRADUALLY REDUCE THE SEDATION AS THE SPASMS DECREASE
IN FRQUENCY AND INTENSITY. THIS MAY TAKE AS LONG AS TWO WEEKS BUT MAY BE MUCH SHORTER.
WHEN SPASMS STOP, ENCOURAGE MOTHER TO KEEP PUTTING THE BABY TO BREAST.
NB!!!

Risk factors for NNT are risk factors for neonatal sepsis, cord sepsis and meningitis, hence
the need to identify these other infections and treat them appropriately. It is common to see a
baby being treated for NNT, with the source of the infection, often the cord, remaining
unclean and badly infected and thus maintaining the infection.
Use of oral sedatives, (crushed tablets down an NG tube) cuts the cost of sedatives by 90%,
and should be used as soon as possible, usually after about the first day of treatment. Passage
of the NG tube should be done under sedation with diazepam, with an ambu bag ready at
hand as it may provoke severe prolonged spasms and consequent apnoea. Once passed, the
NG tube must be firmly taped to avoid the need for re passage.
Sedatives must be written up on a separate sedation chart to avoid confusion. They should be
evenly spaced to provide regular, smooth and sustained sedation.
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7.11.0 KANGAROO MOTHER CARE (KMC)


1. All staff should learn, teach and encourage mothers to practice KMC
2. All mothers should know the benefits of KMC and how to practice KMC
3. Preterm and Low birth babies in stable condition should be placed in KMC position for at least 4
hours in the morning - 8am to 12noon, and 4 hours in the afternoon - 2pm to 6pm.
4. All nurses and other staff should support mothers practicing KMC and allow them to keep their
babies in KMC position for as long as they can.
5. KMC babies should be weighed on alternate days, head circumference and length measured
weekly
6. Monitor temperature 4 hourly
7. Babies can be discharged if feeding well (breastmilk) and gaining weight, and if baby is said to be
well to go home according to the doctor, and mother confident to practice KMC at home
8. Before discharge, the grandmother, father or a relative should be involved in KMC of the baby and
provide support to the mother at home
9. Follow up should be continued until the baby weighs more than 2.5kg

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7.12.0 ANTIBIOTIC PROTOCOL FOR BABIES ADMITTED TO MBU


1. Take BLOOD and CSF for culture before starting antibiotics
2. See the drug dosages chart for the antibiotic dosages
3. Duration of treatment for Staph. aureus and Gram negative sepsis is 14 21 days: parentheral
for at least 7 days
4. Duration of treatment for Coagulase neg. staph sepsis 7 days
First line antibiotics for Sepsis
Cefuroxime and Gentamicin
Second line antibiotics for Sepsis
Cefotaxime or Ceftazidime or Ceftriaxone
Avoid Ceftriaxone in first week of life

First line antibiotics for Cord Sepsis /Cellulitis /Abscess


Flucloxacillin and Gentamicin
First line antibiotics for Meningitis
Crystalline Penicillin and Gentamicin
Second line antibiotics for Meningitis
Ceftriaxone or Cefotaxime or Ceftazidime
First line antibiotics for Osteomyelitis/Septic Arthritis
Flucloxacillin & Gentamicin (at least 14 days parentheral, total duration of treatment is 6 weeks)
Second line antibiotics for Osteomyelitis/Septic Arthritis
Clindamycin
CHANGING FROM FIRST LINE TO SECOND LINE
Should not be based on culture results alone
When patient is clinically not improving eg. temperature spiking or unstable temperature, feeing
poorly, respiratory difficulty etc,
a) Change after 48hrs of antibiotic treatment
b) Change antibiotics based on culture
c) But if culture not yet ready, change to second line
3. Always consult a senior colleague when changing
4. If patient has been on adequate frist line antibiotics before admission, start with second line
5. For all re-admissions who need antibiotics, start with second line
1.
2.

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8.0 FLUID & METABOLIC DISORDERS


8.1.0 DIABETIC HYPERGLYCEMIC CRISIS/COMA
1. RAPID ASSESSMENT
Vomiting, drowsiness, polyuria, polydipsia, abdominal pains, weight loss etc.
i)
Dehydration (-10%) Listlessness, deep rapid breathing, Ketotic (fruity) breath shock, coma
ii)
iii)
Significant hyperglycemia, usually > 17mmol/L
2. Diagnosis of DKA
Hyperglycemia (glucose > 11.1mmol/dl)
i)
ii)
Acidosis (pH < 7.25 or bicarbonate <17)
Ketosis (serum or urine)
iii)

3. MANAGEMENT
Airway, Breathing, & Circulation
i)
ii)
100% O2 to patients with cyanosis/shock or SaO2 <90%
Start IV fluid, insulin, & Potassium as below
iii)
Pass an N-G tube to drain gastric contents in comatose patients.
iv)
v)
Accurately assess urine output.
Suspect cerebral edema if there is a set back after 2-24hrs and treat with mannitol.
vi)
vii)
Find precipitating cause and treat appropriately.
Maintain a flow chart of patients clinical data
viii)

FLUID
i.
ii.
iii.

iv.
INSULIN
i.
ii.

Start intravenous fluid (N/S or R/L) at once to run at 10-20ml/kg/hr (i.e. 0.35ml/kg/min for
1st hr plasma/Haemaccel 10ml/kg IV if shocked).
If no urine is passed, continue IV bolus for 2nd (3rd) hours as well
Calculate fluid requirement for 24hrs. (i.e. maintenance fluid + 10% deficit/ dehydration )
a. Give 1.5 times maintenance for 36-48hrs or
b. Decrease infusion rate to 10ml/kg/hr for next 6-7 hrs.
i. Give the remaining fluid requirement over the subsequent 16 hrs.
Change IVF to 5% Dextrose /saline when blood glucose 11mmol/L.

Start insulin after first hour of NS/LR bolus/rapid infusion is completed.


Start low dose insulin regimen
a) Soluble insulin @ O.1u/kg/hr as IV infusion with a syringe pump,
b) May give first dose IV then subsequent doses IM/IV (e.g. 0.2u/kg/2hrs IM )
b) Reduce insulin dose to 0.05u/kg/hr if child < 5 years or glucose falls more than 4
mmol/L/hr.
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Continue with hourly insulin until blood glucose <10mmol/l and acidosis is controlled (i.e.
base deficit <5 or PH >7.32) then change to sliding scale insulin therapy.
When patient is able to eat change to SC short or intermediate or long acting insulin.

iv.

Sliding scale using 4-6-hourly blood glucose testing


Blood Glucose mmol/L

Insulin dose(SC)

<5

5-9

0.05u/kg

9-11

0.1 u/kg

11-17

0.15u/kg

>17-20

0.2ukg

20

Revert to hourly insulin

ELECTROLYTE
Potassium
i)
When urine flow 1ml/kg/hr, start IV K+, as guided by serum K+,
If serum potassium (K+) < 5mmol/L , give 10-20 mmol per each 500ml IV fluid.
ii)
iii)
iv)
v)
vi)

Obtain serum Potassium 12hrly.


Maintain Potassium level between 4-5mmol/L
DO NOT give Potassium if serum level 6mmo/L
Total Potassium replacement by IV route is NOT NECESSARY, it should be completed orally
when food intake resumes.
Half the Potassium may be given as Potassium phosphate.

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9.0 ONCOLOGICAL DISORDERS


9.1.0 METABOLIC AND ONCOLOGIC EMERGENCIES
9.1.1 TUMOUR LYSIS SYNDROME
This syndrome occur primary in patients with high tumour burden, bulky B-cell or T-cell leukemias or
lymphomas, and can occur in standard-risk acute lymphoblastic leukemia (ALL)
The rapid lysis of blasts (tumor cells) causes a massive release of intracellular contents, particularly
potassium, phosphorus, and nucleic acids resulting in;
a. Hyperkalemia
b. Hyperuricaemia
c. Hyperphosphatemia (accompanied by compensatory hypocalcemia)

Complications
Cardiac arrhythmias
Renal failure
Seizures
Coma
Disseminated intravascular coagulation (DIC)
Death
Management
Administer
Hydration(K+ free), at 2 times maintenance to keep urine specific gravity <1.010.
allopurinol,100mg/m2/dose Q8hr (or10mg/kg/day) PO. May load with 300mg/m2
alkalinization, may give NaHCO3 100mg/kg/day PO Q6-8hrly to keep urine
pH 7.0-7.5. Stop alkalinization if urine pH > 7.5
Strictly monitor urine output, specific gravity and pH (keep urine output >3ml/kg/hr)
Manage metabolic derangement appropriately:
Hyperkalemia (K+>6.0mmol/L)
Do not administer K until tumor lysis is controlled.
Use the following measures to drive K into cells:
Provide hydration and alkalinization.
Nebulize with salbutamol 5mg (2.5mg if <8yr old) Q3-4hrly
Insulin 0.1/kg/hr with glucose 0.5g/kg/hr. Monitor glucose hourly.
10% Calcium gluconate (with onset of ECG changes) 1ml/kg/dose over 5mins.
Consider dialysis if these measures are not successful.
Hypocalcaemia (Ca2+< 0.75mmol/L)
Hypocalcaemia is compensatory to hyperphosphatemia (Ca2+ PO42- <60)
Only treat symptomatic hypocalcaemia (e.g. Tetany).
Give 10% Calcium gluconate at 0.5ml/kg/dose over 5mins. May repeat after 0.5hr
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Hyperphosphatemia
Restrict dietary phosphate
Give Al(OH)3 150mg/kg/day PO 4-6hrly, use with caution in renal failure.
Or Calcium Carbonate (up to 5 tablets 8hrly)
N/saline at 20ml/kg over hr and IV mannitol (use only if renal function is normal)
Consider dialysis, if poor renal function.
Prevention
With 1st course of therapy.
1. Commence allopurinol 24-48 hours before treatment.
2. Prehydrate for 24hours . Do not use fluids containing K. Volume to be given is 3L/m2. Unless
there is renal failure with oliguria, in which case fluid input must be appropriate.
3. May need to alkalinise the urine with IV NaHCO3 at 3 mmol/kg/day.
4. Strict input/output chart.
Monitor the serum electrolytes and uric acid level.

9.1.2 FEBRILE NEUTROPENIA


Definition
Absolute Neutrophil count <1.0 x 109/L and
Temperature 38oC for two hours should be treated as an infection.
Infections caused by both gram negative and gram positive organisms.
Investigations
FBC, Blood Film for mps,
Culture blood, urine, stool ( CSF if indicated); swabs of lesions, throat swabs
Chest x-rays
Abdominal Ultrasound Scan, at least.
Management
Choice of antibiotics1st line  Ampicillin / Co-Amoxiclav and Gentamycin,
2nd lineCefuroxime/Ceftazidime / Ceftriaxone and Amikacin/ Ciproflocaxin,
Meropenem
Remember to give antimalarial treatment.
If fever persists over 48hours, add anti-staphylococcus e.g. Flucloxacillin, but preferably
vancomycin if available.
If fever persists further, consider adding antifungal. The most common fungal infection is candida.
May have to treat possible atypical pneumonia if respiratory symptoms e.g. consider pneumocystis.

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9.2.0 BASIC INVESTIGATIONS FOR ALL ONCOLOGY PATIENTS


General
FBC [Hb, RBCs indices, WBCs total and differential, Platelet] + rectic count film comment
Renal function test:- Na, K, Cl, urea, creatinine, cholesterol, Ca, Mg, inorg PO4
Liver function test
Uric acid, LDH
Chest x ray
Abdominal Ultrasound Scan
Stool R/E
Fine needle aspirate/ biopsy
o Contact pathologists so that reports are obtained within 3 -5 days.
Other laboratory investigations
HIV screen
Bone marrow aspirate
Lumber puncture for CSF (when giving first IT dose)
o cytology or
o may send for cell type and count (to microbiology) if cytology not possible.
Etc etc depending on differential diagnosis.

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9.3.0 RETINOBLASTOMA
Investigations
FBC[Hb, RBCs, WBCs total and differential, Platelet] + rectic count film comment
Renal function test, Blood Urea and electrolyte
Chest x ray
Abdominal Ultrasound Scan
Head CT scan
Tumor aspirate/ biopsy
CSF for cytology.
Refer for ophthalmologist assessment if not already done.
Management
Surgery + Neojuvant/Adjuvant chemotherapy Adjuvant radiotherapy
Many of the cases seen here are advanced and require enucleation followed by chemotherapy within two
weeks of surgery or chemotherapy reduction and then enucleation (usually after two courses of chemo)
followed by further chemotherapy.
If thickened optic nerve on CT scan and /or tumour found at excised optic nerve end then will require
adjunctive radiotherapy.
Six courses of chemotherapy required at 3 weeks interval (check neutrophils count)
IV vincristine 1.5mg/m2 bolus
Etoposide 300mg/m2 in 100 ml N/S over 1 hr
Carboplatin 600mg/m2 in 100mls 5% dextrose over one hour.
o Or Cyclophosphamide 800mg/m2 in 100mls fluid over 30 mins
o Carboplatin preferred if can afford this in place of Cyclophosphamide use;
IT methotrexate and IV vincristine weekly for first 6 weeks.
If bone marrow involvement, ensure it is free (repeat BM) before doing the radiotherapy.

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9.4.0 RHABDOMYOSARCOMA
Investigations
FBC[Hb, RBCs, WBCs total and differential, Platelet] + rectic count film comment
Renal function test, Blood Urea and electrolyte
Chest x ray
Abdominal Ultrasound Scan
Tumor aspirate/ biopsy
Management
Management includes chemotherapy and may require adjunctive surgery to remove residual tumour or
radiotherapy.
TREATMENT
Give at three week interval for a total of 9 courses (27 weeks);
vincristine 1.5mg/m2 bolus
Actinomycin D 1.5mg/m2 bolus
cyclophosphamide 800mg/m2 in 100ml fluid over 30 minutes
weekly iv vincristine 1.5mg/m2 (for the first 6 weeks)
Re-assess after first three full courses of treatment;
If tumour response is over 50% reduction in size then continue for the nine courses.
If tumour response is poor, < 50% reduction, then discuss with consultant and will add further
chemo-agents-e.g. etoposide, carboplatin, doxorubicin in combination.
After six courses, then residual tumour is removed surgically or adjunctive radiotherapy given.

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9.5.0 BURKITTS LYMPHOMA


Clinical features
typical jaw tumor with dental anarchy,
abdominal mass(es) with a highly suggestive ultrasound result (single or multiple homogenous
round masses without capsule
Investigations
FBC[Hb, RBCs, WBCs total and differential, Platelet] + rectic count film comment
Renal function test, Blood Urea and electrolyte
LDH and Uric acid
Chest x ray
Abdominal Ultrasound Scan
Tumor aspirate/ biopsy
Staging
Stage 1 - Single solitary extra-abdominal site
R - Intra-abdominal, more than 90% of tumor resected
Stage 2 -Multiple extra-abdominal tumors
Stage 3 -Intra-abdominal tumor
Stage 4 -Intra-abdominal plus one or more extra-abdominal sites
Management
General supportive care

Ensure good oral hygiene


Note and treat every fever suspicious of neutropenia
Note and treat every pain suspicious of relapse

Ensure frequent voiding (even at night) during treatment with cyclophosphamide to prevent
hemorrhagic cystitis

Treatment divided into Pre-phase and Induction.


The Induction treatment is given in several cycles (minimum 6, or until remission plus 2 cycles).
Clinical follow-up for patients in Remission (treatment completed and tumor not detectable) for at
least one year to detect Relapse.
Preparation for Pre-phase: 24hours before prephase, the patient should be given

Fluids @ 2 - 2.5L/m2 for 24 hrs


Allopurinol @ 10-20mg/kg in 2-3 doses [for the 1st 5 days]
Analgesics if indicated.

Pre-phase
Allopurinol [continue from preparation phase above]
Cyclophosphomade (PO/IV) @ 200mg/m2 daily for 5 days
Induction
Before each cycle of chemotherapy FBC should be done:

If HB<7g/dl hemotransfuse before giving i.v. cyclophosphamide/vincristine.


If total WBC < 3.0 x 109/L and patient not ill, give amoxicillin for 5 days and defer
chemotherapy until total WBC 3.0 x 109/L
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If platelets < 70 x 10 /L defer i.t. methotrexate until platelets 70 x 10 /L

 first course of chemotherapy for all stages

1. IV Cyclophospamide (CTX) 1200mg/m2 OR 40mg/kg over 30mins in 100ml fluid (N/S)


Dose may be given as two half doses; 600mg/m2 each, 48 hrs apart in cases with very
bulky diseases.
2. IT methotrexate(see below for dosages)
If no CNS disease give IT methotrexate stat only
if CNS disease, then give extra
i. IT methotrexate daily x 4 days and tabs folinic acid 15mg tds x 5 days
ii. If no folinic acid then give IT cytarabine 30mg daily x 4 days.
Continue with post-hydration for at least 48 hrs after last dose of CTX.
IT methotrexate dosage by age:
1- 2yr = 8mg
<1yr= 6 mg
2-3yr = 10mg
3yr = 12.5mg
May use midazolam sedation or ketamine
Second and subsequent courses (two weekly intervals)
Check FBC and ensure absolute neutrophils count > 1.0 x 109/L before giving chemotherapy.
Stage 1 and 2
IV Cyclophosphamide 1200mg/m2 over 30 minutes
IT Methotrxate 12.5mg (see dosage if younger than three years)
Give a total of three courses (no pre or post IV fluid hydration required but ensure child tolerating about
2.5L/m2 and there is no vomiting)
STAGES 3 and 4 (combination chemotherapy required)
IV Cyclophosphamide 700mg/m2 in 100mls fluid over 30 mins
IT Methotrxate 12.5mg (see dosage if younger than three years)
IV Vincristine 1.5mg/m2 bolus
IV Doxorubicin (Adriamycin) 30mg/m2 in 250mls over 6 hrs.
*IV metoclopromide 100 micrograms/kg 30 mins before chemo, may repeat after 6 hrs.
Repeat this at two weekly intervals alternating with;
IV Vincristine 1.5mg/m2 bolus
IV Cytarabine (cyctosine arabinoside) 400mg/m2 in 500mls over 24hrs.
IT Methotrexate 12.5mg (see dosage if younger than three years)
IV Cyclophosphamide 700mg/m2 in 100mls fluid over 30 mins
These courses will be given for a total of 4-6 courses (no hydration fluid required)
IT methotrexate is given for only the first three courses.
Relapsed Burkitts lymphoma: combination chemotherapy as above.
May use high dose methotrexate iv in some cases- consultant to decide.

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9.6.0 HODGKINS LYMPHOMA


Investigations
FBC[Hb, RBCs, WBCs total and differential, Platelet] + rectic count film comment
Renal function test, Blood Urea and electrolyte
Chest x ray
Abdominal Ultrasound Scan
Tumor aspirate/ biopsy
Management
TREATMENT
At least Six courses of chemotherapy3 courses of chlVPP alternating with
3 courses of ABVD given at four weeks interval.
COURSE (ChIVPP);
Chlorambucil 6mg/m2 oral once daily x 14days
Vincristine 1.5mg/m2 iv bolus days 1 and 8
Procarbazine 100mg/m2 oral once daily x 14 days
Prednisolone 40mg/m2 oral once daily x 14 days
ALTERNATE WITH(ABVD);
Adriamycin (doxorubicin)25mg/m2 over 6hrs in 5% dextrose days 1 & 15
Bleomycin 10000 iu/m2 iv over 30mins in N/S day 1 & 15
Vincristine 1.5mg/m2 iv bolus day 1 and 15
Dacarbazine 375mg/m2 over 15mins day 1 & 15
Progress to each new course on day 28 provided absolute neutrophils count >1.0 x 109/1.
May have to make modifications if some of the drugs are unavailable.
Central venous lines are advisable with this hybrid protocol.
Calculation of surface area should be based on the Wt/SA chart produced by the UKCCSG Chemotherapy
standardisation working group.

ChlVPP (ONE COURSE)


Drug
Dose
2
Chlorambucil
6mg/m
Vinblastine
6mg/m2 max 10mg
Procarbazine
100mg/m2
Prenisolone
40mg/m2

Route
oral
IV bolus
oral
oral

Frequency
OD
Once each day
OD
OD

95

Days Given
1-14 inclusive of each course
1 & 8 of each course
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ABVD (ONE COURSE)


DRUG
Doxorubicin
(Adriamycin)
Bleomycin

DOSE
25mg/m2

Vincristine

1.5mg/m2
(
max 2mg)
375mg/m2

Dacarbazine

10000 iu/m2

ROUTE
FREQUENCY
IV over 6hrs in 5% dextrose Once on each day
(D5W)
IV over 15-30mins in 0.9% Once on each day
saline
Iv bolus
Once on each day
Iv bolus over 15mins

Once on each day

DAYS GIVEN
1&15 of each
course
1 & 15 of each
course
1&15 of each
course
1&15 of each
course

Note: progress to each new course occurs on day 28 provided


FBC shows
- Platelets > 100 x 1012 /L and
- Neutrophils > 1.0 x 109 / L
Normal Urea, Electrolyte and LFTs
Normal Cardiac function prior to alternate courses of ABVD

9.6.1 TREATMENT PATHWAY IN STAGE II +III HODGKINS DISEASE


DIAGNOSIS

ChlVPPx3 ABVDx3
STOP
IF RELAPSE

EPICx2
RT planning for all patients

EPICX2

EEEEP

GPR

or CR

NO

YES
EE

If radiotherapy

EPICX2

MELPHALAN+PBSC

IF Radiotherapy

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9.7.0 WILMS TUMOUR


Investigations
FBC[Hb, RBCs, WBCs total and differential, Platelet] + rectic count film comment
Renal function test, Blood Urea and electrolyte
Chest x ray
Abdominal Ultrasound Scan
Tumor aspirate/ biopsy
o Contact pathologists so that reports are obtained within 3 -5 da
Management
AFTER investigations and fine needle aspirate, management is by paediatric surgery/urology. Treatment
consists of pre-operative chemotherapy, surgical removal of tumour/ kidney, post operative chemotherapy
and may require adjunctive radiotherapy.
Vincristine @ 1.5mg/m2 bolus weekly x 4 weeks
Actinomycin D @ 1.5mg/m2 bolus at week one and week three.
Note: doses for patients <12kg is reduced to two thirds calculated dose.
Surgery at week 5 6
Post operative chemotherapy given once peristalsis is established following surgery and within 21 days of
last pre-operative chemotherapy.
Duration of post-operative chemotherapy is 27 weeks.
Post operative chemotherapy:
Vincristine @1.5mg/m2 weekly for 8 weeks and then at 3 weekly intervals
i.e. weeks 11, 14, 17, 20, 23, 26.
Actinomycin D @ 1.5mg/m2 bolus weeks 2, 5, 8, 11, 14, 17, 20, 23 and 26
Based on risk assessment some high risk cases will require other drugs and radiotherapy --> consultant to
decide: Drugs include cyclophosphamide, doxorubicin, etoposide, carboplatin.

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9.8.0 PAEDIATRIC ACUTE LYMPHOBLASTIC LEUKAEMIA (ALL)


Investigations
FBC[Hb, RBCs, WBCs total and differential, Platelet] + rectic count film comment
Renal function test, Blood Urea and electrolyte
Chest x ray
Abdominal Ultrasound Scan
Tumor aspirate/ biopsy
o Contact pathologists so that reports are obtained within 3 -5 days.
Management
Cytotoxic drugs are calculated by body surface area (BSA)
BSA (M) = Square root of [Height (m) x Weight (kg) /3600) or use chart to convert from kg.
Treatment is given as pre-treatment phase, followed by regimen A or B induction phase, followed by
maintenance.
Regimen A induction for patients age<10yrs and highest recorded total WBC count <50 x10 9/L.
Regimen B induction for patients age 10yrs and/or highest recorded total WCC >50 x10 9/L.
9.8.1 PRE-TREATMENT PHASE

Commence as soon as diagnosis confirmed either by blood film or bone marrow aspirate review by
haematologist.
For patients with clinic suspicion of CNS disease see notes at end of protocol
Hydration is commenced maximal oral fluids, supplemented for 48hrs with 2-2.5L/m2/24hrs iv.
Allopurinol is commenced 10-20mg/kg/day po in 2 divided doses for 7 days
Prednisolone 2mg/kg po daily in the morning.
o If WCC80x109/L the pre-treatment phase continues for 7days
o If WCC<80x109/L the pre-treatment phase continues for 2 days
Once pre-treatment phase completed patient commences day 1 of induction with regimen A or B
depending on their highest recorded WCC and age as above.

9.8.2 REGIMEN A INDUCTION

Prednisolone 2mg/kg po in the morning day 1-28, then 1.5mg/kg for 2 days, 1mg/kg for 2 days,
0.5mg/kg for 2 days, then stop.
Vincristine 1.5mg/m 2 (max dose 2mg) iv day 1, 8, 15, 22, 29)
Intrathecal Methotrexate dose by age:
o <2yrs=7.5mg,
2yrs=10mg,
3yrs = 12.5mg
o Day 9, 16 and 23 (see intrathecal notes)
Cotrimoxazole by BSA on day of vincristine and following days (Day 1,2,8,9,15,16,22,23,29,30)
o 0.5-0.75 m2 =240mgbd,
o 0.76-1.0m2 =360mg bd,
o >1.0m2 = 480mg bd
Folic Acid 5mg PO daily day 1-30
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Reviews during regimen A induction:


1. Patient can be discharged once diagnosis confirmed and iv fluids discontinued if they are
afebrile, well enough to be managed at home and parents understand the drug regimen and
plan for review. Parents must also understand indications for returning for earlier review.
2. Check FBC on day 30 to see if ready to progress to maintenance (neutrophil count more than
0.75x109/L and platelet count > 75x109/L). If counts too low request blood film review by
haematologist ?needs BM aspirate or ?non-responder/relapse.
9.8.3 REGIMEN B INDUCTION

Prednisolone 2mg/kg po in the morning day 1-28, then 1.5mg/kg for 2 days, 1mg/kg for 2 days,
0.5mg/kg for 2 days, then stop
Vincristine 1.5mg/m2 (max dose 2mg) iv day 1,8, 15,22, 29
Doxorubicin 25mg/m2 iv day 8 and 22
Cyclophosphamide 750mg/m2 iv day 29 and 36
6-mercaptopurine 75mg/m2 po daily day 30 onwards irrespective of blood counts. Do not take milk
simultaneously
Intrathecal Methotrexate dose by age: ,2yrs =7.5mg, 2yrs=10mg, 3yrs or more = 12.5mg day 9,16,23,
and 30 (see intrathecal notes)
Cotrimoxazole by BSA on day of vincristine and following day (Day 1,2,8,9,15,16,22,23,29,30)
o 0.5.-75 m2 =240mg BD,
0.76-1.0m2 =360mg BD,
>1.0m2 =480mg BD
Folic Acid 5mg po daily on day 1-30

Reviews during regimen B induction:


1. Patient can be discharged once diagnosis confirmed and iv fluids discontinued if they are
afebrile, well enough to be managed at home and parents understand the drug regimen and
plan for review. Parents must also understand indications for returning for earlier review.
2. Check FBC on day 43 to see if ready to progress to maintenance (neutrophil count more than
0.75x109/1 and platelet count >75x109/1). If counts too low adjust dose of 6-mercaptopurine
as below and repeat FBC on day 50. If count still too low omit 6mercaptopurine and request
FBC with blood film review by haematologist on day 57  ?needs BM aspirate - ?nonresponder/relapse.

9.8.4 MAINTENANCE

1. Commence once induction completed, PLUS Neutrophil count > 0.75x109/L and PLT > 75x109/L.
2. Should be continued for 48 weeks in four cycles of 12 weeks (84days)
Intrathecal Methotrexate dose by age:
<2yrs = 7.5mg,
2-3yrs = 10mg,
3yrs = 12.5mg day 1
6-mercaptopurine 75mg/m2 po daily day 1-84 (see below re dose adjustment). Do not take milk
simultaneously
Oral Methotrexate 20mg/m2 po weekly day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, 78
(weekly, but omit on day of intrathecal metehotrexate) (see below re dose adjustment)
Vincristine 1.5mg/m2 (max dose 2mg) iv day 15, 43, 71 (ie week 3,7, 11)
Prednisolone 2mg/kg po day 15-19, 43-47, 71-75 (ie for 5 days week 3,7,11)
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Clinic visits during maintenance:


Patient should attend for FBC on the day prior to intrathecal methotrexate and attend with the results to be
checked prior to drug administration platelet count must be >50x109/L and patients card.
The IV vincristine and PO Prednisolone are then given.
Notes:
6-mereaptopurine and oral methodtrexate dose adjustment during maintenance
The doses should be adjusted to maintain the neutrophil count between 0.75 and 1.5x109/1 and platelets
between 75 -150x109/L.
If the neutrophil count falls to 0.5 - 0.75x109/L halve the dose of 6-mercaptopurine and oral methotrexate.
Check FBC weekly and restart the 6-mercaptopurine (75mg/m2 po daily) and oral methotrexate (20mg/m2
po weekly) when the neutrophil count is > 0.75x109/L.
If the platelet count falls to between 50 -75x109/L halve the dose of 6-mercaptopurine and oral
methotrexate.
If the platelet count falls to < 50x109/L. STOP the 6-mercaptopurine and oral methotrexate. Check FBC
weekly and restart the 6-mercaptopurine (75mg/m2 po daily) and oral methotrexate (20mg/m2 po weekly)
when the platelet count is >75x109/L.
If both the platelet and neutophil counts fall, adjust dose according to which has the biggest drop and
ensure that both rise with dose adjustment.
Intrathecal Methotrexate
It is imperative that vincristine is NOT given via the intrathecal route.
In order to avoid this occurring intravenous vincristine should NOT be given on the same day as intrathecal
methotrexate.
The only drugs that can be given by the intrathecal routs are methotrexate, hydrocortisone and cytosine.
10 drops of CSF should be collected into a sterile container and taken to the haematology lab for a slide to
be made and a white cell count done. If the CSF WCC is >0.1x109/L and RCC<1x109/L discuss with
haematologist ?CNS involvement/relapse.
Who should be admitted to the ward
1. Patients that are neutropenic (neutrophil count<1.0x109/L) and febrile (Temp. > 38OC) should be
assessed and admitted to the ward for broad spectrum antibiotics as per the neutropenic sepsis
regimen.
2. Patients that are too unwell to be managed at home e.g. Diarrhea or vomiting requiring intravenous
fluids, hypoxia, severe uncontrolled pain.
3. Patients with clinical evidence of CNS disease at presentation (neurological deficit) and patients who
have blasts in their CSF
o These patients should be treated as per regimen B unless too unwell to treat (at the
discretion of the specialist)

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Relapse and Non-Responders


These patients should be given palliative treatment only eg dexamethasone (discuss with the specialist)
Considerations for the future
Asparaginase could be added to the regimen if it becomes more readily available locally small doses of iv
cytosine could be added to regimen B induction if this becomes more readily available locally.
General Rules

Patients are enrolled into the treatment programme through a specialist.


Pre-phase helps to reduce the risk of tumour lysis syndrome. If cyclophosphamide tabs cannot be
swallowed, pre-phase can be given i.v.
Laboratory investigations before treatment (minimum) includes Hb, WBC and platelets (renal
function and electrolytes are not necessary in my opinion urinary output is more important);
LDH is not a necessary parameter only if it is high before starting treatment, then it may be
able to monitor remission and relapse)
X-rays are usually not helpful and in classical presentation not needed should be indicated by
specialists;
Ultrasound of abdomen in all cases desirable

Pre-phase and first cycle of induction is given as in-patient treatment


Subsequent cycles can be given as out-patient treatment.
On each visit
History of fever, pain, mouth sores, appetite, weight loss, skin/joint problems, activity
O/E temperature, weight, pallor, inspection mucous membranes and skin for infections,
Lab: FBC (Hb, WBC, Platelets) + MPs
Reasons to defer treatment:

If HB below 7g/dl defer cycle for 5 days but give oral dexamethasone (O.6mg/kg in 2-4 doses
If platelets below 100ml defer intrathecal methotrexate (without delaying the next i.v cycle)
If malaria positive, but not ill treat malaria and give chemotherapy
If malaria positive, but very ill treat malaria first and discuss with specialist (child may be ill
because of the tumour!!)
If fever for no obvious reasons treat with antibiotics and discuss with senior.

When to discuss a patient

When tumour increases during treatment


When patient ill
When fever without explanation
When any reason to defer treatment persists more than one week (do not forget it is the tumour
that kills the patient!!!)
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6-mercaptopurine and request FBC with film FAO haematologist on day 27? Needs BM aspirate - ?nonresponder/relapse.
Maintenance
Commence once induction completed and neutrophil count > 0.75x109/L and platelet count more than
75x109/L
Should be continued for 48 weeks in four cycles of 12 weeks (84 days)
Intrathecal Methotrexate dose by age:
<2yrs=7.5mg
2yrs=10mg,
3yrs =12.5mg day 1
6-mercaptopurine 75mg/m2 po daily day 1-84 (see below for dose adjustment) [Do not take milk
simultaneously]
Oral Methotrexate 20mg/m2 po weekly day 8,15,22, 29, 36, 43, 50, 57, 64,71, 78
(weekly, but omit on day of intrathecal methotrexate) (see below re dose adjustment
Vincristine 1.5mg/m2 (max dose 2mg) IV day 15, 43, 71 (i.e. week 3, 7, 11)
Prednisolone 2mg/kg po day 15-19, 43-47, 71-75 (i.e. for 5 days in weeks 3, 7, 11)
Clinic visits during maintenance:
Patient should attend for review on days 15, 43, and 71(i.e. 4 weekly). They should have FBC checked the
day before. The patient and FBC result should be reviewed (fro side effects of treatment and possible signs
of relapse especially). Dose adjustments should be made to the oral methotrexate and 6-mercaptopurine
doses (see below) and documented in the patients card. The iv vincristine and po Prednisolone are then
given.
Notes:
6-mercaptopurine and oral methotrexate dose adjustment during maintenance
The doses should be adjusted to maintain the neutrophil count between 0.75 and 1.5x109/1 and platelets
between 75 and 150x109/1.
If the neutrophil count falls to between 0.5 and 0.75x109/L. HALVE the dose of 6-mercaptopurine and oral
methotrexate.
If the neutrophil count falls to <0.5x109/L. STOP the 6-mercaptopurine and oral methotrexate. Check FBC
weekly and restart the 6-mmercaptopurine (75mg/m2 po daily) and oral methotrexate (20mg/m2 po weekly)
when the neutrophil count is >0.75x109/L.
If the platelet count falls to between 50 and 75x109/L. HALVE the dose of 6-mercaptopurine and oral
methotrexate.

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If the platelet count falls to <50x109/L. STOP the 6-mercaptopurine and oral methotrexate. Check FBC
weekly and restart the 6-mercaptopurine (75mg/m2 po daily) and oral methotrexate (20mg/m2 po weekly)
when the platelet count is .75x109/1.
If both the platelet and neutrophil counts fall dose adjust according to which has the biggest drop and
ensure the both rise with dose adjustment.
Intrathecal Methotrexate
It is imperative that vincristine is NOT given via the intrathecal route. In order to avoid this occurring
intravenous vincristine should not be given on the same day as intrathecal methotrexate.
The only drugs that can be given by the intrathecal route are methotrexate, hydrocortisone and cytosine.
10drops of CSF should be collected into a sterile container and taken to the haematology lab for a slide to
be made and a white cell count done. If the CSF WCC is > 0.1x109/L and RCC >1.0x109/L discuss with
haematologist ?CNS involvement /relapse.
Who should be admitted to the ward?
Patients that are neutropenic (neutrophil count < 1.0x109/L) and febrile (Temp. 380C) should be
assessed and admitted to the ward for broad spectrum antibiotics as per the neutropenic sepsis
regimen
Patients that are too unwell to be managed at home e.g. diarrhea or vomiting requiring intravenous
fluids, hypoxia, and severe uncontrolled pain.
Patients with clinic evidence of CNS disease at presentation (neurological deficit) and patients who
have blasts in their CSF
These patients should be treated as per regimen B unless too unwell to treat (at the discretion of the
specialist)
Relapse and Non-Responders
These patients should be given palliative treatment only e.g. dexamethasone (discuss with the specialist)
Considerations for the future
Asparaginase could be added to the regimen if it becomes more readily available locally small doses of iv
cytosine could be added to regimen B induction if this becomes more readily available locally

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9.9.0 SOME COMMON DRUGS USED IN PAEDIATRIC ONCOLOGY PATIENTS

IV Cyclophosphamide dose over 30mins in 100mls fluid(N/S)


IV vincristine dose bolus
IV Etoposide dose in 100ml N/S over one hour
IV Doxorubicin (Adriamycin) dose in 250mls over 6 hrs.
IV Carboplatin dose in 150ml 5% dextrose over one hour.
IV Actinomycin D dose bolus
IV Bleomycin dose over 30 mins in N/S
IV Dacarbazine bolus over 15mins
IT Methotrexate is age dependent:
<1yr= 6 mg
1-< 2yr = 8mg
2-< 3yr = 10mg
>3yr = 12.5mg

NOTE
Vincristine maximum dose 2mg
Actinomycin D maximum dose 2mg
Infants under 1 year and children with weight < 10kg give two thirds of calculated doses of
chemotherapy.
Do not give actinomycin D/doxorubicin within two weeks of radiotherapy.
EXTRAVASATION OF DRUGS
Vincristine, Actinomycin D, doxorubicin.
Local injection of hydrocortisone- infiltrate of site as much as possible.
For vincristine, immediate application of warm compress will increase circulation and encourage
absorption of drug from tissues to blood stream.
After one hour, a cold compress may relieve swelling and inflammation.
Early application of ice pack for other drugs.
Where skin damage is extensive, early referral to plastic surgeon.
Antiemetic
IV Metoclopromide 100 micrograms/kg 30 mins before chemotherapy, may repeat after 6hrs.
IV/ oral dexamethasone 1-4mg 8 hourly.
IV Granisetron 40 mcg/kg before chemotherapy.
Sedation
IV Midazolam 100mcg/kg but doses up to 300mcg/kg may be used.
Analgesia
Mild pain-paracetamol
Moderate pain -dihydrocodeine paracetamol
Severe pain
- oral morphine
Opiates may cause constipation so consider stool softeners.
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10.0 PAEDIATRIC EMERGENCIES


10.1.0 HYPOGLYCAEMIA
1. DEFINITION
Surrogate marker for harmfully low levels of energy in the central nervous system.
Blood glucose 2.0mmol/L (serum/plasma glucose 2.5mmol/L) or BM stix 3.0mmol/L
2. COMMON CAUSES
Metabolic
Ketotic hypoglycaemia after short period of starvation in young children
Infections
Severe malaria
Septicaemia in young children/severe malnutrition
Liver disease
Reye syndrome
Acute liver failure
Hepatic failure/dysfunction
Inborn errors of metabolism
Glycogen storage disorders
Galactosaemia
Hereditary fructose intolerance
Poisoning
Alcohol
Aspirin
Hormonal
Hormone excess
Insulin
-administered insulin in diabetes or poisoning
-Drug (e.g. Quinine) induced
-Insulinoma
-Beckwith syndrome
Hormone deficiency
Growth hormone
-Growth hormone deficiency
ACTH
-Panhypopituitarism
Cortisol
-Addison disease
-Congenital adrenal hyperplasia
Miscellaneous:
Malaria
Diarrhea
Malnutrition

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3. CLINICAL FEATURES
Sweating
Pallor
CNS signs of irritability, headache, seizures and coma
4. DIAGNOSIS / ASSESSMENT
High index of suspicion as symptoms can be subtle
Do blood glucose in any child who:
-appears seriously ill
-has a prolong seizures
-has altered sensorium
5. TREATMENT / MANAGEMENT
a. BOLUS
5ml/kg IV bolus of 10% Dextrose over 5 10 minutes ( or mini bolus of 2ml/Kg for Neonates)

Rapid bolus of 5ml/kg of 10% Dextrose or


o

2ml/kg of 25% Dextrose may be given per rectum (as retain enema) or

per gastric tube (if able to tolerate enteric feeding).

If child is conscious, give 50ml 10% sugar solution or start feeding immediately.

b. CONTINUOUS INFUSION
10% (5-12.5%) Dextrose containing fluid at maintenance rate (or rate of 4-8mg/kg/min)

Repeat blood sugar every 30mins until blood sugar is stable, then continue blood sugar monitoring
at less frequent interval till patient is stable

Keep blood sugar between 4-12mmol/L.

If blood sugar is < 4mmol/L, repeat a bolus (or mini-bolus 2ml/Kg) of glucose and review infusion
rate. DO NOT over infuse (i.e. Avoid fluid overload).

Oral / gastric tube feeding should be commenced as soon as child is able to tolerate oral feeds or
tube feeding.

*INTRAMUSCULAR (IM) THERAPY (use only in place of bolus dextrose)


Glucagon @ 0.03/kg IM/SC stat (max. dose 1mg)

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10.2.0 FLUID THERAPY


10.2.1 SHOCK
1. DEFINITION:A state of inadequate or inappropriate tissue perfusion and/or oxygenation.
Shock results from an acute failure of circulatory function. Maintenance of adequate tissue perfusion and
oxygenation depends on:
a pump (the heart)

cardiogenic shock

the correct type and volume of fluid


(blood)

hypovolaemic shock

controlled vessels (arteries, veins, and


capillaries)

failure leads to

distributive shock

unobstructed flow

obstructive shock

red blood cells

dissociative shock

The most common causes of shock in the paediatric patient are


hypovolaemia from any cause, including trauma
septicaemia,
the effects of trauma and
very severe anaemia.
2. TYPES & CAUSES OF SHOCK
Hypovolaemic:DehydrationBlood lossPlasma loss-

Acute Watery Diarrhoea, diabetic ketoacidosis


trauma
nephrotic syndrome, burns

Maldistribution of fluid:-

Septicaemia
Anaphylaxis
Bowel obstruction
Splenic Sequestration

Cardiogenic:-

Arrhythmias
Heart/Pump failure
Cardiomyopathy

Obstructive:

Hypertension
Cardiac tamponade
Tension pneumothorax

Dissociative:

Profound anaemia
Carbon monoxide poisoning

Septic :

Maldistribution/Hypovolaemic plus cardiogenic


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3. CLINICAL SIGNS:Early (compensated)


Tachycardia
Tachypnoea
Decreased skin turgor
Delayed capillary refill (>4secs)
Mottled pale, cold skin
Core-peripheral temperature gap (>4oC)
Decreased urinary output

Late (decompensated)
Acidotic (Kussmaul) breathing
Hypotension (SBP < [70+2[age in yrs]])
Confusion/depressed consciousness
Absent urine output

Diagnostic pointers
A history of vomiting and/or diarrhoea points to fluid loss either externally (eg gastroenteritis) or
into the abdomen (e.g. volvulus, intussuception, early stages of gastroenteritis)
Fever or a rash points to septicaemia
Urticaria, angio-neurotic oedema or a history of allergen exposure points to anaphylaxis
Cyanosis unresponsive to oxygen or signs of heart failure in a baby under 4 weeks points to ductdependent congenital heart disease
Signs of heart failure in an older infant or child may points to severe anaemia (usually with severe
pallor) or cardiomyopathy
A history of sickle cell disease or diarrhoeal illness and low haemoglobin points to acute haemolysis
A history of major trauma points to blood loss, and more rarely, tension pneumothorax,
haemothorax, cardiac tamponade or spinal cord transection
Severe tachycardia or signs of heart failure point to an arrhythmia or to a cardiomyopathy
A history of polyuria, sighing, respirations and a very high blood glucose points to diabetes (see
Diabetic ketoacidosis)
A history of drug ingestion points to poisoning
4.

MANAGEMENT PRIORITIES:Fluid resuscitation (key element to the successful treatment of shock)


Ensure adequate Airway and Breathing. Give O2, support ventilation if needed.
Rapid restoration of the intravascular circulating volume is most critical.
Start 20ml/kg of 0.9%Normal Saline / Ringers Lactate over 20mins (may modify if myocardial
dysfunction likely).
Reassess. If no improvement, repeat 0.9%Normal Saline / Ringers Lactate @ 10ml/kg in 10-15mins
(up to max. 60ml/kg), there after consider inotropes with further fluid therapy
Reassess. If replacement requires >40ml/kg or if acute blood loss, consider haemacell, plasma (FFP),
or red blood cells (packed or whole) @10ml/kg.
If cardiogenic etiology is suspected, fluid resuscitation may worsen clinical status.

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10.2.2 NORMAL MAINTENNANCE FLUIDS


i) Age <6 months

- 100 -120ml/kg/day.

ii) Age >6 months

-for first 10kg,


-for next 10kg,
-every additional weight >20kg,

Electrolyte
Sodium
Na+
Potassium K+
Chloride Cl-

100ml/kg/day
50ml/kg/day
20ml/kg/day

mmol/100ml of water
3
2
2

e.g. 25kg girl would need (10 100ml)+(10 50ml)+(5 20) = 1700ml/day of fluid
= 51mmol of Na+/day
(173)mmol of Na+
+
= 34mmol of K+/day
(172)mmol of K
(172)mmol of Cl= 34mmol of Cl-/day
TYPES OF FLUIDS:a. Crystalloid solutions
Half strength Darrows solution in 2.5-5% Dextrose
Frequently used for rehydration & maintenance in infants & the malnourished.
Ringers lactate solution
Used for rehydration & volume expansion.
0.9% Normal saline solution
Used for rehydration & volume expansion.
5-10% Dextrose in 0.9% Normal saline solution.
Used as maintenance solution.
2.5-10% Dextrose in Ringers lactate solution.
Used frequently for rehydration & as maintenance solution
10% dextrose in 1/5 strength Normal Saline (0.18% Saline)
b. Colloid solutions-( Haemaccel, Albumin,Plasma etc.)
Used for volume expansion
c. Blood
Packed cells (pRBCs)
Used for chronic anaemia
Whole blood
Used for hypovolaemic shock due to haemorrhage or sequestration

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NOTE:
DO NOT give fluids containing no sodium to patients with meningitis unless you are just keeping the
line open.
REMEMBER to restrict to 70% maintenance in meningitis after correction of intravascular volume
deficit.
NEVER give only Dextrose for more than 24hrs. Change to, or alternate with crystalloid.
FAST REHYDRATION
Give rehydration requirement over 4-6hrs followed by the days maintenance given over the next 20hrs
Fast rehydration is most appropriate if child is in shock.
Fast rehydration is contra-indicated in:Severe malnutrition
Hypernatraemia
Hyperosmolar state (e.g. hyperglycaemic crisis/coma)
SLOW REHYDRATION
Add rehydration requirement to childs maintenance for 24-36hrs and give the total amount of fluid
gradually over 24-36hrs.
Slow rehydration is most suitable in:Severe malnutrition
Hypernatraemia
Hyperosmolar state (e.g. hyperglycaemic crisis/coma)
NOTE:
In either fast or slow rehydration, correct shock with fast/bolus IV fluid @ 15-20ml/kg over 10-20mins
[preferably 30mins] (15ml /kg over 60mins for the SEVERELY malnourished child).
May repeat IV bolus @ 10ml/kg in 15 min (15ml/kg/60min in PEM) till peripheral pulse palpable (or up
to 60 80ml/kg).
Consider inotropes in septic shock( after adequate hydration) or Cardiogenic shock

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10.2.3 DIARRHEA AND DEHYDRATION


1. ASSESSMENT
A

Condition

Well

Restless, Irritable

Lethargic or unconscious

Eyes

Normal

Sunken

Very sunken

Thirst

Normal

Thirsty and drinks


eagerly

Drinks little or none

Skin Pinch

Quick return

Slow return
(1-2secs)

Very slow return


(>2 secs)

MILD-MODERATE
~7.5% ( 6 - 10)

SEVERE
>10%

DEHYDRATION loss of <5%


body weight

Note: Need two or more clinical signs in a category for classification.


2. MANAGEMENT.
PLAN A.
HOME MANAGEMENT OF ONGOING FLUID LOSS
i.)
Give ORS/Food based fluid little and often at 10ml/kg or in the following volumes:AGE
FLUID VOL. PER EACH LOOSE STOOLS
VOLUME / DAY
< 24 months
50-100ml
500ml
2-10 years.

100-200ml

1000ml

>10 years.

as much as is wanted

2000ml

ii)

Continue breast-feeding or feeding solids.

iii)

Bring the child back to hospital if


a. repeated vomiting
b. Fever
c. Bloody stools
d. Not better in 3 days

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PLAN B. MILD MODERATE DEHYDRATION.


Give ORS @ 75ml/kg in the first 4hrs.
i)
If patient cannot drink give IV Ringers Lactate @ 75ml/kg in the first 4hrs
Then start ORS 5ml/kg /hr as soonas patient can drink
Continue feeding (Brest milk and/or energy-rich, easily digestible foods).
ii)
NB. Explain to mother exactly how much to give, how often and to give it little and often e.g. a teaspoon
every 1-2mins.
REGULAR REASSESSMENT IS CRUCIAL !!!
PLAN C. SEVERE DEHYDRATION.
i) Give IV Ringers Lactate as follows:AGE
30ml/kg in
<12 months
1 hour
Older

30 min.

70ml/kg in
5 hours
2.5 hours

ii) Start ORS 5ml/kg/hr as soon as the child can drink.


iii) If IV/IO access is impossible give 20ml/kg/hr of ORS continuously by an NG tube for 4-6 hours. Keep
retrying for IV access & re-assessing. Consider intraosseous (IO) route.
iv) Rehydrate a child with severe malnutrition more slowly.
v) KEEP REASSESSING THE PATIENT !!!

USE OF DRUGS IN DIARRHOEA.


1. ANTIDIARRHOEAL DRUGS AND ANTIEMETICS should NEVER be used.
2. ANTIBIOTICS should ONLY be used for
i. Suspected Bacillary Dysentry (e.g. CIPROFLOXACIN @ 15mg/kg Q12h for 3 days)
ii. -Suspected Cholera
a. TETRACYCLINE if >8years old @ 12.5mg/kg Q6h for 3 days;
b. Erythromycin if < 8yrs 12.5mg/kg Q6h for 3 days.
iii. -Other indication e.g. meningitis, otitis media, UTI or suspected
septicaemia/urosepsis.
3. ANTIPARASITIC DRUGS should ONLY be used for
-Amoebiasis (METRONIDAZOLE) IF bloody stools did not improve on
i.
ciprofloxacin or IF trophozoites of E. Histolytica are seen in the stools.
-Giardiasis (METRONIDAZOLE) ONLY IF diarrhea has lasted over
ii.

14 days or cysts or trophozoites of Giardia are seen in the stools.


4. Oral Zinc supplementation (if <6mths 10mg/day, 6mths 5yrs @ 20mg/day) for 2 weeks

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10.2.4 DIARRHOEA / DEHYDRATION (EXCLUDING SEVERE MALNUTRITION)


ALGORTHM
History of diarrhoea / vomiting, age > 2 months

CRITICAL.
Prostrated / Unconscious with weak or
no pulse palpable plus one of:
capillary refilling > 3 seconds,
return of skin pinch >2 seconds.
NB if Hb<6g/dl transfuse urgently,
20mls/kg.

Yes

Ringers Lactate or Normal Saline 20mls/kg


over 10 - 30 minutes, then continue as below
(repeat bolus once if no improvement after
first bolus).
Reassess and re-classify
Consider treatment for hypoglycaemia.

No
SEVERE.
Lethargy, pulse OK but unable to drink
adequately plus one or more of:
sunken eyes
return of skin pinch >2 seconds
Capillary refilling > 3 seconds

No

MODERATE
Able to drink adequately but 2 or
more of:
Sunken eyes
Return of skin pinch 1-2 secs
Capillary refilling > 2 seconds
Drinks eagerly

Yes

Ringers Lactate or Normal saline @ 30mls/kg


Either:
Over 1hr if 1 yr old or,
Over 30min if >1yr old.
Re-assess and re-classify

Re-assess clinical signs and condition at least hourly, and at


least after 4 hours re-classify on the basis of signs as severe,
moderate or mild and treat according to classification.

Yes

a. ORS by mouth/ngt at 75mls/Kg over 4hrs


[or 20mls/kg/hour for 4 hours]
Use IV Ringers Lactate at 75mls/kg/4 hours ONLY
if enteric route not feasible or vomit >3X/hr. Plus
Breast feeding / feeding as tolerated
Continue as below if improving, repeat step if
no improvement.

No
MILD (Should be outpatient unless
there is another problem)
Diarrhoea / GE with fewer than 2 of
the above signs of dehydration

i)

Yes

ORS by mouth at 10mls/kg per loose


stools, plus
ii) Continue breast feeding / feeding as
tolerated

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11.0 RENAL DISORDERS


11.1.0 GENERAL GUIDE FOR ALL RENAL CASES

Efforts should be made to arrive at a definitive diagnosis irrespective of the Referring/Admitting


diagnosis.
All cases should have the renal data (enclosed in patients folder) filled in whole by the attending
doctor (i.e. the admission data, laboratory data, and discharge data).
BP should always be re-checked on admission using the appropriate cuff size and must be plotted
on the appropriate BP centile chart for height, age, and sex.
Body weight should be measured every other day.
Urine output should be measured daily over 24 hours and recorded in mls/kg/hour.
All cases should have a repeat dipstick urinalysis on the bedside by the attending doctor (at booking
to the ward/unit)
All cases should have culture of an appropriately collected urine sample done on admission.
The under-listed investigations should be done ROUTINELY for all cases:
I.
Blood
Full Blood Count (haematology)
Chemistry BUE, Creatinine, Albumin & Total Protein, Cholesterol,
Ca2+, Phosphorus, and Alkaline Phosphatase
Urine
Dipstick + microscopy
C/S
Stool R/E
III.
Ultrasonography scan of Kidneys and urinary tract
IV.
V.
Other Investigations as may be necessary
All cases should have their GFR estimated using the Schwartz formula for children:
GFR(ml/min/1.73m2) =
K X
height (cm)
Serum Creatinine (mol/L)
Where K is:
40 for neonates and infants younger than 1 yr,
49 for children 1 12 years
49 for adolescent females, 13 21 years
60 for adolescent males, 13 21 years
II.

Minimum urine output:

>1ml/Kg/hour in children
>2ml/Kg/hour in infants

Appropriate dietary advice should be given in all cases (see overleaf)

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11.2.0 DIETARY ADVICE FOR RENAL CASE


A) For all cases in Renal Failure:
Avoid Potassium-rich food like banana, coconut, and tomatoes
Avoid Phosphorus-rich diet like milk, and diary products
Limit 24-hour fluid intake (water and all other drinks including fluid diet) to insensible loss
(500 mls/m2 ) + Previous days output
Protein intake should not exceed 2g/kg/day
Promote high Caloric-diet
Avoid nephrotoxic drugs like Gentamycin
Adjust doses of all drugs as appropriate
Prescribe low salt diet
Do Renal function test weekly (urea, creatinine and electrolytes, including serum calcium
and phosphate levels)

B) For Grossly edematous patients including Nephrotic Syndrome:


Limit fluid intake to insensible loss (500 mls/m2) + Previous days output
Prescribe low salt diet

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11.3.0 NEPHRITIC SYNDROME (ACUTE GLOMERULONEPHRITIS)


11.3.1 CLINICAL DEFINITION/CRITERIA

Definition
For the purpose of this protocol, acute nephritic syndrome shall be defined by acute onset of any
combination of:
1. haematuria (pink or brownish urine)
2. oliguria
3. oedema
4. hypertension
5. azotaemia
6. red cells and red cell cast and/or granular cast on urine microscopy
7. moderate proteinuria
Common causes include:
postinfectious (Strep & Staph)
IgA nephropthy
Henoch-Scholein syndrome
Membranous proliferative
SLE
ANCA and anti-glomerular basement membrane disease
All cases should be assumed to be of postinfectious aetiology unless proven otherwise

11.3.2 MANAGEMENT GUIDELINES FOR NEPHRITIC SYNDROME (AGN)

.Routine laboratory tests


1. Urine dipstick for protein, blood, leucocyte & nitrite
2. Urine microscopy, C & S
3. Full blood count
4. Blood chemistry (Na, K, Cl, urea, creatinine, albumin, total protein, cholesterol, Ca, Mg, inorg PO4)
5. HBsAg
6. VDRL
7. HIV (only after counselling)
8. CXR for any evidence of cardiomegaly and pulmonary oedema
Other laboratory tests e.g. ANA, anti-dsDNA, ANCA, anti GBM may be requested on selected cases
Management Principles
Control hypertension with appropriate anti-hypertensives, preferably amlodipine (5mg or 10 mg)
Give diuretics (frusemide) to control the fluid overload
Reinforce dietary management (see above)

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Management
1. Daily weight
2. Daily fluid intake versus output chart
3. Strict fluid balance (intake to strictly match previous days output + insensible loss use 300ml/m2)
4. Strict salt restriction including all known salt-rich food
5. Amoxycillin 15mg/kg/dose 8 hourly for 5-7 days
6. Lasix 1mg/kg/dose 8-24 hourly. IV lasix 2-4mg/kg slowly over 5-10 mins if in pulmonary oedema
7. Dialysis (see indications below)
Indications for dialysis
1. Hyperkalaemia not responding to medical treatment
2. Pulmonary oedema unresponsive high dose IV lasix
3. Rapidly Progressive Renal Functional Impairment
4. Anuria not responding to high dose IV lasix

11.3.3 COMPLICATIONS & THEIR MANAGEMENT

1. Stage 2 Hypertension (BP > [99th percentile for age, sex & height + 5 mmHg])
Note:

Stage 1 hypertension usually can be controlled on diuretics alone

Amlodipine 0.2mg/kg/day. For younger children who are fast metabolisers, the dose could be
given 12 hourly
Atenelol 1-2mg/kg/12-24hourly
Continue diuretic

2. Hypertensive encephalopathy
IV labetalol (continuos IV infusion @ 0.5mg/kg/hr, adjusted interval > 15min; max 3mg/kg/hr) or
IV hydrallazine 0.1-0.2mg/kg q30mins-60mins. These should be titrated to achieve a gradual
and gentle fall in BP by 1/3 in the 1st 24 hrs, 1/3 in the next 24 hrs and 1/3 in the final 24 hours
IV Lasix 1-2mg/kg
IV mannitol 0.25-0.5mg/kg over 30 mins
Commence oral antihypertensives as soon as stable to take. Preferably use short acting drugs
like Nifedipine
3. Pulmonary oedema
Confirm with urgent CXR
Prop up and give O2
IV Lasix (high dose) 4-5mg/kg slowly over5-10mins
Acute dialysis
4. Congestive cardiac failure
Manage as per Pulmonary oedema

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5. Hyperkalaemia
Put on cardiac monitor to see ECG changes
Commence nebulised salbutamol 5mg 2-hourly whilst serial levels of potassium are determined
Kayexalate 0.5-1g 6-hourly (per rectum or orally)
Soluble insulin in 10% Dextrose to run at 1units of insulin/5g of dextrose over 1 hour whilst RBS
is checked frequently.
Dialysis if the above Rx fail
6. Rapidly Progressive Renal Functional Impairment
Defined by escalating levels of BUN, Cr decreasing urine output
All cases should undergo emergency renal biopsy
Commence IV methyl prednisolone 10mg/kg/day x 5
Consider dialysis

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11.4.0 NEPHROTIC SYNDROME


11.4.1 CLINICAL DEFINITION/CRITERIA FOR NEPHROTIC SYNDROME:

Definition
In this protocol, nephrotic syndrome (NS) shall be defined as triad of
Urinary protein of 3+ or more on dipstick, or protein/creatinine ratio of >0.2 (g/l/mmol/l) of early
morning urine
Hypoalbuminaemia of < 25g/l
Clinical oedema
Hypercholesterolaemia is invariably present but not needed for diagnosis

11.4.2 MANAGEMENT GUIDELINES FOR NEPHROTIC SYNDROME

Routine laboratory tests


The following tests should be done in ALL confirmed cases of NS
1. Blood chemistry (Na, K, Cl, urea, creatinine, albumin, total protein, cholesterol, Ca, Mg, inorg PO4)
2. Full blood count + PCV
3. EMU protein/creatinine ratio
4. Urine electrolytes + fractional excretion of sodium
5. Urine dipstick for leucocyte & nitrite. If either or both is +ve, do urine C&S
6. Blood for HBsAg
7. Blood for VDRL
8. HIV (only after counselling)
9. CXR for any evidence of PTB
10. Mantoux test
11. Stool for strongyloides and other parasites
Other laboratory tests e.g. ANA, anti-dsDNA, ASO & anti-DNASe titres may be requested on selected cases
Management
A) Adjunctive/Supportive therapy
1. Daily weight
2. daily fluid output chart
3. If urine output is low from history or from output chart, then limit fluid intake to match previous
days output + insensible losses (300-500ml/m2)
4. Low salt diet
5. Amiloride (alone or as combined tablet with thiazide e.g moduretic) lasix if grossly oedematous.
Hypovolaemia should always be ruled out before starting diuretics. Discontinue all diuretics with
complete resolution of oedema
6. Pen V prophylaxis if grossly oedematous

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7. Albumin infusion (1g/kg/day) or plasma (10ml/kg/day) may be prescribed for very severe oedema
to run for 3-4 hours. Either should be given with IV lasix 1mg/kg half-way into infusion. Repeat at
end of infusion.
Note: ACEI & statins should NOT be prescribed routinely for acute cases.
They should be reserved for chronic nephrotics (see definition below) and SRNS.
B) Corticosteroids
Steroid shall be the cornerstone of treatment for all cases of confirmed nephrotics but their use is NEVER an
emergency. They should only be started after the diagnosis has been confirmed and all potential infections
have been ruled out (see under routine laboratory tests). Also, make sure that blood pressure is normalised
with antihypertensives before commencing on steroids.
Induction of remission
Prednisolone 60mg/m2/day for 28 days per os.
In overtly oedematous cases in which absorption from GI may be suspect , IV methylprednisolone
10mg/kg/day may be given for the initial 3 days.
If proteinuric at end of 28 days, declare as steroid resistant and prepare for renal biopsy (see subsequent
treatment below).
Steroid sensitive
If steroid responsive/sensitive (i.e. ve or trace proteinuria on dipstick for 3 consecutive days within the first
28 days of steroids), document time duration at which response occurred. However, for the purpose of this
protocol, all steroid responsive cases should continue the high dose prednisolone (60mg/m2/day) for 6
complete weeks.
Maintainance of remission
Prednisolone 40mg/kg/day on alternate days for 6 complete weeks, then taper over 2 weeks by 25%
decrement every 3rd day.
The above treatment protocol shall apply to all steroid sensitive cases who relapse for the first 2 instances.
STEROID RESISTANT NEPHROTIC SYNDROME (SRNS)
For the purpose of this protocol, steroid resistance shall be defined as 1+ or more of dipstick proteinuria
after 28 days of 60mg/m2/day of prednisolone.
For all such cases, the following actions should be taken:
1. Quantify proteinuria by EMU protein/creatinine ration. This will differentiate partial response
(pro/creat of < 0.2) from incomplete response (pro/creat of > 0.2)
2. Arrange for renal biopsy (see pre-biopsy preparation below)
3. Continue high dose prednisolone (60mg/m2/day) while waiting for histology report.

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For all SRNS, high dose prednisolone (60mg/m2/day) may be continued for 12 weeks after which
40mg/M2 given on alternate days for another 12 weeks may be given. Thereafter, wean off
prednisolone over 2 weeks (decrease by 25% each 3rd day) and reinforce adjunctive therapy.
4. Adjunctive therapy shall be reinforced and shall consists of the following:
Low salt diet
Amiloride (alone or as combined tablet with thiazide e.g moduretic) if grossly oedematous.
Discontinue all diuretics with complete resolution of oedema
Pen V prophylaxis if grossly oedematous
Albumin infusion (1g/kg/day) or plasma (10ml/kg/day) may be prescribed for very severe
oedema to run for 3-4 hours. Either should be given with IV lasix 1mg/kg half-way into infusion.
Repeat at end of infusion.
ACEI ARB
Statin
Blood pressure control
Adequate nutrition
Aspirin (for mesangial proliferative, membranous and membranous proliferative see below)

Further immunosuppressive therapy will to be guided by biopsy report as follows:


1. Minimal change
Continue high dose prednisolone for 6 complete weeks.
Responsive to 6 weeks steroid
If responds at end of 6 weeks, declare as late steroid resistance and give maintenance prednisolone
40mg/m2/day for 12 complete weeks and wean off over 2 weeks.
No response after 6 weeks steroid: give cyclophosphamide
If no response at end of 6 weeks, start 2nd line agent cyclophosphamide for 3 months. Continued the
steroid while on the cyclophosphamide.
Responds to cyclophosphamide
If response to cyclophosphamide, give maintenance prednisolone 40mg/m2/alternate day for another 12
weeks and then wean off over 2 weeks.
No response to cyclophosphamide; give cyclosporin
Give 3rd line agent cyclosporin for 12 years. At this juncture, side effects of steroid may be problematic.
If so, the dose of prednisolone may be decreased to 40mg/m2/day while on cyclosporin.
Responds to cyclosporin
If responds to cyclosporin, wean off steroids and continue cyclosporine for 1-2 yrs.
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No response to cyclosporin
Declare treatment resistant. Stop all immunosuppressants and emphasise adjunctive therapy.
Prepare for another biopsy.
Mesangial proliferative
Treat as steroid resistant minimal change but add aspirin to adjunctive therapy
2. Focal segmental glomerulosclerosis
Continue high dose prednisolone 60mg/m2/day for 3 complete months and maintenance dose
40mg/m2/alternate day for another 3 months.
No response to 6 months prednisolone
Give cyclophosphamide for 3 months. Here, the steroid dose should be tapered to low tolerable dose on
alternate days.
No response to cyclophosmamide
Give cyclosporin for 2 years. If responds to cyclosporin, wean off steroids and continue cyclosporin
Prepare for renal biopsy after 2 years on cyclosporin
3. Membranoproliferative/Mesangiocapillary
1. Adjunctive therapy as cornerstone of treatment
2. Aspirin
3. Prednisolone on alternate days for 2 years cytotoxics
4. Membranous
Always rule out secondary causes in children (e.g. HBV, syphilis, SLE, drug exposure like gold & Hg).
1.
2.
3.
4.
5.
6.

High rate of spontaneous remission in the 1st 12 months


Adjunctive therapy cornerstone in treatment
Aspirin.
Statins.
ACEI, ARB to control proteinuria
Immunosuppressants are reserved for caes that manifest nephrotic proteinuria. NEVER give
steroids alone!
Medrol 10mg/kg/day on day 1-3 followed by prednisone to complete 1st month. Alternate
monthly with cyclophosphamide for total of 6 months of combination therapy

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11.4.3 SECONDARY CAUSES OF NEPHROTIC SYNDROME

All should undergo renal biopsy


HIV associated nephrotic syndrome
1. ARVs shall be cornerstone of treatment
2. Adjunctive therapy
Hepatitis B Virus associated nephrotic syndrome
1. No immunosuppresives unless rapidly progressive glomerulonephritis. Risk of converting stable
chronic persistent hepatitis to chronic active hepatitis if immunosuppressant are given without prior
antiviral therapy.
2. Adjunctive therapy shall be cornerstone of therapy
3. Antiviral therapy (Interferon , lamivudine, tenofovir) if affordable.
Watch renal function closely if tenofovir is given due to potential nephrotoxicity.
Syphillis
Pen G for 14 days
Adjunctive therapy
Look for contact and treat also
SLE (+ve ANA & anti-dsDNA) associated nephrotic syndrome (i.e. WHO class V)
1. Remission shall be induced as follows:
IV medrol 10mg/kg/day x 3 to be followed by prednisolone 1mg/kg/day x 4 weeks, then
prednisolone 0.75mg/kg/day x 4 weeks. Thereafter, taper prednisolone (if disease is well controlled)
for long-term therapy
IV cyclophosphamide 500-1000mg/m2 monthly x 6
2. Maintenance therapy shall consist of:
Azathioprine 2mg/kg/day in the long-term till in remission for at least 1 year
Low dose prednisolone 0.5mg/kg/alternate days to control extra renal disease
3. Extra renal disease (musculoskeletal, skin, serosa) shall be controlled with NSAIDs, chloroquine and
the low dose prednisolone.
4. Aspirin shall be given if anticardiolipin/antiphospholipid positive
Note: Disease activity shall be monitored both by clinical symptoms/signs and laboratory tests.
Laboratory tests:
1. Urine dipstick and microscopy
2. ESR
3. Anti nuclear antibody (ANA) and anti double strand DNA titres
Exacerbation of disease activity shall be treated with pulse medrol and high dose prednisolone IV
cyclophosphamide
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11.4.4 COMPLICATIONS OF NEPHROTIC SYNDROME & THEIR MANAGEMENT

1. Hypovalaemia
Suspect if:
complaint of abdominal pain without tenderness
history of diarrhoea and/or vomiting
oliguria
urine Na <10mmol/L or FENa < 1%
2. Spontaneous bacterial peritonitis
Do blood and peritoneal fluid C&S
Start IV Penicillin + Gentamycin x 7 days
3. Cellulitis
Do pus swab if there are open discharging wound
Start on Co-Amoxiclav for 7 days OR IV Cefuroxime if too ill.
4. Venous thrombosis
Suspect if asymmetrical limb swelling, gross haematuria in purnephritic (Renal vein
thrombosis)
Confirm with Doppler ultrasound scan
Treat with heparin and subsequently warfarin

Definitions in Nephrosis

Remission- urine albustix ve or trace for 3 consecutive days

Relapse urine albustix 2+ ( oedema)having achieved remission previously


Frequently relapsing -2 or more relapse in the 1st 6mths after presentation or 4 relapses
within any 12 mths period
Steroid dependant relapse whilst on steroid therapy or within 14 days of
discontinuation of steroid
Steroid resistant failure of proteinuria to resolve ff 28 days of Pred at dose of
60mg/m2/day
Congenital Nephrotic NS occuring in 1st 3 months of life
Infantile Nephrotic NS occuring b/n 3 mths -1 yr of life

Treatment of Relapse

For infrequent relapses ( 2X in 6 mths or < 4 in a yr)) the same regimen as for the initial
presentation is recommended.
For frequent relapses (>2X within 6 mths of initial response or > 4x within any 12
months period), low dose steroid (0.5mg Pred/kg/alt day) should be given for 3-6mths.

For those who relapse while on alternate day steroid Or within 2 wks of cessation of steroid
(steroid dependent), the lowest dose of prednisolone at which remission is sustained should be
used.

Ketrax (levamisole) 2.5 mg/kg/alt days may be given for 4-12 mths.
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Indications for renal biopsy


Age <12 months or > 12 years
SRNS
Atypical features
Initial macroscopic hematuria at any age (in the absence of infectn or renal vein thrombosis)
Evidence of vasculitis
Persistentent HPT
Persistent impaired renal function
Low C3
Hepatitis B or C serology, HIV
Protocol for Performing Renal biopsy
1. Book with the sonographer (Radiologist)
2. Do baseline KUB USS. A small shrunken kidney is not biopsyable.
3. Obtain inform consent from Parents/Guardians
4. Do FBC, Coagulation screen (PT, PTT, INR), BUE, Cr)
5. Maintain normotension
6. Keep patient nil per os overnight
7. Do blood grouping and cross match and safe
8. Obtain IV line access

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11.5.0 URINARY TRACT INFECTION


Definition: bacteriological diagnosis based on culture of a single bacterial species of appropriate colony
count from appropriately collected urine;

for suprapubic aspiration (SPA), any amount of bacteria count or growth


for mid stream urine (MSU) or clean catch, colony count of >100,000/ml urine
for catheterised urine sample, colony count of > 10,000/ml
Lower bacterial counts (1000/ml) may be accepted if prior antibiotic intake.

Always state clearly on the laboratory request form the type of urine sample and antibiotic history.
Non-bacterial pathogens e.g fungus (candida) and virus may be considered significant particularly for the
immunocompromised.
Bagged urine collection is not suitable. It may only be used for screening purposes.
Clinical suspicion: Suspect UTI in any child with the following:

fever in the infant and young child in whom symptoms may be non-specific
any child with urine dipstick positive for leucocyte and/or nitrite, or pus cells >10/HPF on
microscopy
dysuria, frequency of micturation, loin pain, 20 enuresis, offensive urine.

Classification:

lower tract infection (cystitis) and upper tract infection (pyelonephritis).


Pyelonephritis represents the most severe form and carries the risk of renal scaring. It is
often not possible to localize the site of the infection.

Cystitis is often associated with only low grade fever whilst pyelonephritis is often associated with
temperatures > 390C.
Treatment
For children with severe symptoms or in whom pyelonephritis is suspected, treatment should be
commenced straight away once urine sample has been collected preferably with IV antibiotics.
For less severe symptoms, antibiotics can wait till after culture and sensitivity results.
Choice of antibiotics:
Parenteral antibiotics:

gentamycin 7.5mg/kg OD
ciprofloxacin 10mg/kg 12hrly
2nd/3rd generation cephalosporin e.g.
o 30-50mg/kg cefuroxime BD or
o 50mg/kg ceftriaxone OD
Co-amoxiclav 15mg/kg/dose of amoxil TDS

Oral antibiotics:

ciprofloxacin 15mg/kg BD
Co-amoxiclav 15mg/kg of amox BD
cefuroxime 10mg/kg BD
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Note: co-trimoxazole and amoxicillin are ineffective therapies for UTI in this locality*
Duration of therapy: 5-7 days for cystitis. 7-14 days for pyelonephritis.
All children should have follow up urine C/S done at least 48hrs after completing antimicrobial therapy to
document cure.
Antibiotic prophylaxis: This may be considered for newborns and young infants with culture-proven UTI
who are yet to have radiological evaluation to rule out underlying structural abnormalities. It should be
considered for all children with proven underlying urinary tract abnormalities.
Choice of prophylaxis:

cefuroxime (for newborns) 5mg/kg BD


nitofurantoin (1mg/kg nocte)
nalidixic acid(7.5mg/kg BD)

Radiological investigations
For this protocol, all children with culture-proven UTI should have radiological investigation to rule out
underlying structural abnormality or renal scarring as follows:

kidney, ureter and bladder (KUB) ultrasound request ALL CASES


micturiting cystourethrogram (MCUG)-done only after UTI has been cured:
o for all children under 2 years
o for all boys
o for all cases abnormality on ultrasound
IVU for all cases of suspected Pelvicoureteric junction obstruction or renal scaring. Nuclear
imaging is the ideal test and may be requested for at other institution.

Other radiological investigations may be discussed with the Nephrologist or Radiologist.

*Antwi et al. Urine dipstick as a screening test for urinary tract infection. Ann Trop Paediatr 2008; 28:117122

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11.6.0 ACUTE RENAL FAILURE


Definition
In this protocol, ARF shall be defined as
An elevated serum creatinine greater than the acceptable range of normal for age in the setting of
risk factor for acute kidney injury (see below) in a patient with known normal renal function for the
preceding 3 months
OR
1.5-fold rise (50% ) in serum creatinine or an absolute in serum creatinine of 26.4 mol/l
from known baseline value occurring within 48 hours.
OR
a sudden decreased in urine output of < 0.5ml/kg/hour for any duration > 6 hours.
For any patient with known chronic kidney disease, the occurrence of any one of the above shall be defined
as acute-on-chronic renal failure. Efforts should thus be made to identify any remediable event (e.g.
infection, urinary tract obstruction & dehydration) that precipitated such failure.
The following serum creatinine values shall be used:

Newborns(1st 7 days of life)..................27-88 mol/l


Infant......................18-35 mol/l
Child.....................27-62 mol/l
Adolescent....................44-88 mol/l

Acute Renal failure is POTENTIALLY REVERSIBLE if intervention is instituted early. Every effort should
therefore be made in getting input from the Paediatric Nephrologist whilst primary intervention is
instituted by the attending Clinician.

Evaluation

A. History
Any event that is known to potentially cause kidney injury should be clearly identified and noted. These
include:
Pre-renal events
1. Volume loss e.g. from diarrhoea & vomiting, haemorrhage, burns, 3rd spacing
2. Hypotension from any cause
3. Sepsis
4. Decreased renal perfusion e.g. from shock including Algid malaria
5. Vasoconstriction from radiographic contrast
Renal events
1. Hypoxia
2. Nephrotoxic agents including drugs like gentamycin
3. Muscle injury or intravascular haemolysis (passage of dark urine)
4. Sepsis
5. Glomerulonephritis
6. Pyelonephritis and other causes of tubule-interstitial nephritis
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7. Haemolytic Uraemic syndrome


8. Tumour infiltrate
Post-renal events
1. Poor urine stream e.g. dribbling of urine
2. Difficulty in voiding
3. History of kidney stones (colicky pain in the flank bloody urine)

B. Physical findings
1. Determine volume status (volume deficit e.g cold extremities, weak pulse, CRT, skin turgor for
pre-renal ARF; volume overload e.g. engorged neck veins, oedema in the absence of hypovolaemia
for post-renal ARF)
2. Blood pressure (hypotension for pre-renal ARF, hypertension for renal ARF)
3. Palpable kidneys or palpable bladder (post-renal ARF)

C. Investigations
1. Urine dipsticks
2. Urine microscopy, C&S
3. Urine electrolytes + fractional excretion of sodium (FENa).
4. Blood chemistry (Na, K, Cl, urea, creatinine, albumin, total protein, cholesterol, Ca, Mg, inorg PO4)
5. Blood gas
6. Full blood count
7. KUB ultrasound
Other tests should be determined by suspected diagnosis e.g. Urine calcium/creatinine ratio for suspected
hypercalciuria
Useful discriminatory tests between Pre-reanal ARF and Intrinsic ARF
Parameter

Pre-renal

Intrinsic ARF

History

Volume loss +ve

Volume loss ve (or very long duration)

Volume status

N or

BP

or paradoxically

N or

Urine-Na

< 10mmol/l

> 20mmol/l

FE-Na

< 1%

> 1%

Fluid challenge

+ve response

No response

BUN/Scr

> 20:1

< 20:1

Urine microscopy

Normal or non-specific findings

Granular/tubular cell cast/red cell cast

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Urine Sodium X Serum Creatinine X100


Urine Creatinine X Serum Sodium

Management
General Principles
Establish the cause of the ARF as much as possible
For all suspected post-renal causes, URGENT KUB ultrasound should be requested
Avoid on-going kidney injury with nephrotoxins like gentamycin and NSAIDs
Look for acute complications (see below) and treat
Steps in Management:
1. Pass indwelling catheter for strict urine output monitoring (measure in ml/kg/hour). Catheter will
also relieve obstruction in post-renal causes
2. Fluid challenge with N/Saline 20ml/kg infused over 30 min 1 hour for all cases of suspected prerenal cause in the absence of obvious volume overload. Fluid bolus may be repeated x 2.
In the absence of obvious fluid overload, try fluid challange if not sure of cause of ARF.
Monitoring should, however, be done for iatrogenic pulmonary oedema (increasing breathlessness, new
onset basal crackles, new onset facial oedema and/or hepatomegaly, RR, HR)
3. If hypovolaemic despite fluid resuscitation, give ionotropes (dopamine, dobutamine or
norAdrenaline/Adrenaline) to maintain normal BP
4. Fluid restriction in established intrinsic ARF. if oliguric give insensible loss [400ml/m2/day] +
previous days output. If markedly hypervolemic and anuric, total fluid restriction
5. Fluid replacement if polyuric particularly after relief of obstruction in post-renal ARF or following
recovery in ATN
6. Diuretic challange for persistent oligo-anuria despite adequate fluid resuscitation. Lasix 2mg/kg I.V.
stat. A second dose of 5mg/kg may be given slowly over 5-10 mins if no satisfactory response.
Alternatively, lasix infusion 0.5-1mgkg/hr may be given aminophylline infusion 0.7mg/kg to run for
6 hours. New infusion should be prepared every 6 hours.

Complications of ARF and their Management


1. Hyperkalaemia (See also under Nephritic syndrome)
Put on cardiac monitor to see ECG changes
Stabilise myocardial with Ca gluconate 10% (0.5ml/kg IV over 10 min)
Commence salbutamol nebulisation 5mg 2-hourly (2.5mg if < 5yrs) whilst serial levels of potassium
are determined
Kayexalate 0.5-1g 6-hourly (per rectum or orally)
Soluble insulin in 10% Dextrose to run at 1units of insulin/5g of dextrose over 1 hour whilst RBS is
checked frequently.
NaHCO3 1 mmol/kg/day but be careful with associated in intratravascular volume
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Dialysis if the above treatment measures fail

Supporting measures in treatment of Hyperkalaemia


Avoid K-rich diet
Avoid drugs that cause hyperK+
2. Pulmonary oedema
Confirm with urgent CXR
Prop up and give O2
IV Lasix (high dose) 4-5mg/kg slowly over5-10mins
Acute dialysis invariably
3. Hypocalcaemia/Hyperphosphataemia
If symptomatic hypocalcaemia (tetany or convulsion), then give IV Ca gluconate
Phosphate binders per oral with food e.g. CaCO3, Al(OH)3
4. Metabolic acidosis
Treat with NaHCO3
5. Hypertensive encephalopathy (See also under Nephritic syndrome)
IV labetalol (continuos infusion) or IV hydrallazine 0.1-0.2mg/kg q30mins-60mins. These should
be titrated to achieve a gradual and gentle fall in BP by 1/3 in the 1st 24 hours, 1/3 in the next 24
hours and 1/3 in the final 24 hours
IV Lasix 1-2mg/kg
IV mannitol 0.25-0.5mg/kg over 30 mins
Commence oral antihypertensives as soon as stable to take. Preferably use short acting drugs
like Nifedipine

6. Hyponatraemia
Restrict all plain water intake
If symptomatic, treat with IV 3% NaCl
Indications for dialysis in ARF
Failure of conservative Management
Pulmonary oedema unresponsive to diuretics
Hyperkalaemia not controlled by conservative treatment
Severe metabolic acidosis
Oligo-anuria
Uraemic pericarditis
Multisystem failure
Severe hyponatraemia
To make room for volume therapy (e.g. Transfusion, TPN) in the oligo-anuric patient
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11.7.0 CHRONIC RENAL FAILURE/CHRONIC KIDNEY DISEASE


Definitions
1. Chronic kidney disease (CKD)
Any kidney injury that last > 3 months. Such injury may be defined by structural or functional abnormalities
as follows:
o serum urea & creatinine
o Proteinuria haematuria
o Abnormal renal imaging.
o Abnormality on kidney biopsy.
2. Chronic renal failure (CRF)
Irreversible lost of renal function with a resulting decrease in GFR and a slowly creeping serum creating.
CRF occurs on the background of chronic kidney injury, leading to loss of functional renal mass small
shrunken kidneys.
Since the kidneys maintain a large functional reserve, the renal damage must exceed 50% of the nephron
population for CRF to develop. In CRF, there is significant impairment of the synthetic function anaemia,
and Renal Osteodystrophy (ROD) .
Classification/Staging of CKD
In this protocol, all children with CKD shall have GFR estimated by the Swart formula and staged according
to the National Kidney Foundation Disease Outcome Quality Initiative (K/DOQI) guidelines as follows:
Swart formula:
Estimated GFR (eGFR)
= height (cm) x K
Serum creatinine (mol/l)
Where K = 40 for children < 1 year
49 for all children 1-12 yrs old
49 for adolescent females 13-21 yrs
60 for adolescent males 13-21 yrs
NKF-K/DOQI classification of chronic kidney disease (CKD)
Stage of CKD

GFR(ml/min/1.73m2)

Description

90

Kidney damage with normal or increased GFR

60-89

Kidney damage with mild reduction of GFR

30-59

Moderate reduction of GFR

15-29

Severe reduction of GFR

< 15

End stage renal failure

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Clinical suspicion
Suspect CRF in any child with renal failure who has any of the following:
growth failure
anaemia (usually normocytic normochromic)
hypertension
rickets
Investigations
The following investigations shall be done for all children with CRF
1. Ultrasound of the Kidneys, ureters, and bladder (KUB)
2. Blood urea, creatinine, electrolytes, Ca2+, Mg2+, PO4-, albumin, total proteins, cholesterol, alkaline
phosphatise, liver transaminases (ALT & AST).
3. Urine dipstick, microscopy and C/S
4. Serum parathyroid hormones
5. Blood gases
6. Full blood count
Other investigations may be determined by individual cases.
Treatment
Rx focuses on measures aimed at slowing progression of CKD to ESRFand shall consist of the following:
Reduce proteinuria with ACEIs & angiotensin receptor blocker e.g losartan. Beware of side effect of
hyperkalaemia.
Control hypertension with antihypertensives. Aim for BP < 90th centile for age & sex
Control fluid overload with fluid restriction and high dose lasix (up to 5mg/kg may be given BD-TDS)
metolazone.
Control lipidaemia with statins especially chronic nephrotics. Statins also have anti-inflammatory
effects that help to reduce chronic glomerular inflammation.
Control ROD with PO4 binders (e.g. CaCO3) given with every meal & calcitriol/1 vit D3 0.25g1g/day
Control acidosis with NaHCO3 50-100 mmol/kg/day in 2-4 divided doses (titrate against blood pH)
Manage anaemia with Inj. erythropoeitin (20-50U/kg subcut 2-3x/week) & haematinics
Manage hyperkalaemia with kayaxelate 0.5-1g/kg QID. Lasix and metolazone may also help to
control hyperkalaemia.
Ensure adequate nutrition to allow for growt. Up to 2g/kg protein per day may be given. The
support of nutritionist may be needed here.

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12.0 RESPIRATORY DISORDERS


12.1.0 INTRODUCTION
Respiratory disorders are second to malaria in frequency of occurrence in Ghana. Among the Respiratory
disorders seen in this hospital Acute Respiratory Infections are the most common.
Common symptoms at presentations are Cough, fast breathing, wheeze, stridor, hoarseness of voice, Lower
chest in-drawing. Children often present with a combination of symptoms which would suggest the
diagnosis. They may lead eventually to respiratory failure and death.

Criteria for fast breathing in Children:


Age in months
< 2 mths
2 - 11 mths
12 mths and over

Maximum respiratory rate


expected for normal
60 cycles /min
50 cycles / min
40 cycles / min

Pattern of Presentation of common respiratory disorders:

Features of common respiratory disorders at presentation


Condition

Croup
Epiglotitis
Inhaled Foreign Body

Pneumonia
Asthma

Pulmonary TB

Symptoms and signs


Fast
Cough
breathing
Yes

(barking)
Yes

Wheeze

Stridor

Grunting

Onset

Short history

(depending
on level)
-

Short history

Sudden

Short history

Yes

Yes
Yes
(morning
and night)

(depending
on level)

Sudden or
gradual

Yes

Weeks to
months

Infections are often associated with fever at onset


Severe forms present with Lower Chest In-drawing (LCI)

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12.2.0 RESPIRATORY FAILURE


1. Definition:
Inability of the respiratory system to provide sufficient oxygen for metabolic needs or to excrete CO2
produced.
Biochemical indicators:
[Normal PaO2 11-13 kPa or 83-98 mmHg]
PaO2 <8 kPa (60 mmHg)
or
PaCo2 >7 kPa (55 mmHg). [Normal PaCo2 4.8-6.0 kPa or 36-45 mmHg]
Signs of hypoxia: Restlessness , Confusion, Central cyanosis. If long standing, Polycythemia, Pulmonary
hypertension, Cor pulmonale
Signs of Hypercapnia: Headache, peripheral vasodilatation, bounding pulse, Tremors, confusion,
drowsiness, coma.
2. Types of Respiratory failure:
Type I respiratory failure: Low PaO2 with normal or low PaCO2
Associated with diseases that damage lung tissue causing acute hypoxaemia
e.g. Pneumonia, Pulmonary oedema, Acute lung injury.

Type II respiratory failure (ventilatory failure): Low PaO2 with high PaCO2
Associated with conditions in which alveolar ventilation is insufficient to excrete the volume of
carbon dioxide being produced by tissue metabolism.
Asthma
Acute epiglottitis
Anaphylaxis
Poliomyelitis
Bulbar syndromes
Inhaled foreign body
Respiratory depressants (drugs)
3. Principles of Management of Respiratory failure:

Treat underlying cause


Give oxygen
Assisted ventilation (bag and mask)
If this fails consider intubation and ventilation

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12.3.0 CROUP
Definition
A respiratory infection that occurs mainly in children, particularly from 2 to 4 years of age, due
inflammation of the upper airway from the larynx to main abd branch bronchus.
Symptoms/Signs
Preceded by an URTI (cough, rhinorrhoea, pharyngitis, low grade fever).
Stridor, barking cough, hoarse voice, suprasternal and intercostals indrawing, cyanosis, agitation,
respiratory distress, unconsciousness in severe cases
Use scoring system to judge severity if croup is suspected .
Mild croup: Occasional barking cough; no stridor at rest; and no to mild suprasternal, intercostal
indrawing (retractions of the skin of the chest wall), or both corresponding to a Westley croup score of
02.
Moderate croup: Frequent barking cough, easily audible stridor at rest, and suprasternal and sternal
wall retraction at rest, but no or little distress or agitation, corresponding to a Westley croup score of 3
5.
Severe croup: Frequent barking cough, prominent inspiratory and occasionally expiratory stridor,
marked sternal wall retractions, decreased air entry on auscultation, and significant distress and
agitation, corresponding to a Westley croup score of 611.
1.

CAUSES
Viral laryngotracheitis (very common) e.g. RSV, hMPV etc
Recurrent or spasmodic croup (common)
Bacterial tracheitis (rare)

2.

ASSESSMENT
Peak age 6 months to 3 years, 80% <5 years.
Hoarseness or muffled voice
Drooling
Stridor
Barking cough
Respiratory rate
Fever
Severity of upper airway obstruction best assessed clinically by:
 Increase agitation (Irritability and/or anxiety)
 Drowsiness, tiredness, exhaustion
 Heart Rate
(Tachycardia)
 Degree of retractions (sternal and subcostal recession)
 Pulsus paradoxicus
 Central cyanosis
 Croup score*

3. COMPLICATIONS
Hypoxia (Oxygen saturation by pulse oximetery, blood gases rarely indicated)
Dehydration
Respiratory failure

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4. INVESTIGATION
o AP and lateral neck x-ray (may not be important for classical cases)
5. MANAGEMENT
Mild (no stridor at rest), i.e. Westley Croup Score < 3
o Minimal disturbance, hydration antipyretic.
Moderate to severe i.e. Westley Croup Score > 2
o Admit if croup score is greater than 2
o Minimal handling of patient
o Adequate hydration , preferable orally, antipyretic
o Place child in position of comfort humified oxygen
o nebulized adrenaline (1ml of 1:1000 plus 3ml N/saline),
 nebulize with 0.5 - 1ml of prepared solution, diluted to 2-3ml, may repeat >1hrly
 rebound phenomenon can occur, monitor HR, RR, & Retraction
o steroid
 Administer Dexamethasone 0.6mg/kg PO /IV/IM stat./daily (max. dose 16mg)
 nebulized pulmicort 2mg/4ml 0.9% Normal saline stat.
o monitor carefully for signs of deterioration or worsening of score
o urgent tracheal intubation is required in <1% for respiratory failure
o Intubation and tracheostomy should be done by an experienced person if indicated

(impending respiratory failure/arrest)


If child fails to respond as expected to therapy, consider lateral neck radiography and evaluation by
ENT surgeon for retropharyngeal abscess, bacterial tracheitis, and foreign body
Westley Croup Score
Score
0

Clinical Feature
Stridor
None
With agitation
Retractions
None
Mild
Cyanosis
None
...
Consciousness Normal/Asleep ...
*Mild croup (0-2)
**Moderate croup (3-5)

At rest
...
...
Moderate
Severe
...
...
...
With Agitation
...
...
...
***Severe Croup (6-11)

Discharge criteria
Discharge if

Westley Croup Score <3 [ i.e. Mild croup], and


At least 3 hours post adrenaline nebulization
And no other indication for admission exists.

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0
None
Normal

Cyanosis
Inspiratory Breath
sounds
Stridor
None
Cough
None
Retractions & Flaring None

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CROUP SCORE
1
In room air
Harsh with rhonchi

2
In 40% O2 [FiO2=0.4]
Delayed

Inspiratory
Hoarse
Flaring & suprasternal
retraction

Inspiratory & Expiratory or at rest


Bark
Flaring & suprasternal retraction plus
Sub coastal and intercostals recession

Note:
o Croup Score 4 is indicative of moderately severe airway obstruction,
o Croup Score 7 ( PaCO2 >45 and PaO2 <70mmHg in room air) indicative of impending respiratory
failure

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12.4.0 ASTHMA
1. DIAGNOSIS

2.

Recurrent reversible airway obstruction


Wheeze / Cough (especially nocturnal)
Difficulty in breathing /Prolong expiratory phase
More than 15% improvement in Peak expiratory flow rate (PEFR) after inhaled salbutamol
(suggestive)
Rule out other causes of wheeze (e.g. foreign body airway obstruction,bronchiolitis,
Pneumonia in very young children, etc)
High association with allergic phenomena (especially allergic rhinitis (common), eczema)
PATHOPHYSIOLOGY
Bronchoconstriction
Mucosal oedema
Excessive mucous production

3. CLINICAL SUSPICION
High Index
 Frequent wheeze
(>1/ month),
 Exercise/Activity-induced cough or wheeze
 Nocturnal cough in periods without colds

Predictor in later Childhood


 Wheeze before the age of 3,
PLUS
 one major risk factor:

 Absence of seasonal variation in wheeze,


and

parental history of asthma

 Persistent symptoms after age 3.

eczema

OR

 (Exercise test responses in the field)

 two of three minor risk factors:

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4. ASSESSMENT AND FEATURES OF SEVERE / LIFE-THREATEN ASTHMA


Severe asthma
Life-threatening asthma
Heart rate (HR)

>140/min

*Respiratory rate (RR)

>50/min

Poor respiratory effort

Expiratory wheeze

Silent chest

Oxygen saturation (SaO2)


too breathless to talk / feed

Dyspnoea / Speech

Words only
Reduced conscious level

Alertness

Fatigue, agitation, drowsiness


<33% predicted / best value

*Use of accessory muscles


Peak expiratory flow rate

<60% predicted / best value

Cyanosis

Colour / Cyanosis

Nil

>20mmHg

Pulsus paradoxus

10 - 20mmHg

*NOTE:Wheeze and respiratory rate are poor indicators of severity.


I.
Disappearance of wheeze may actually signify very severe bonchconstriction (silent chest).
II.
Contraction of stenomastoids, chest recession and pulse rate are better guides.
Status Asthmaticus:
Definition: Any asthmatic attack that fails to respond to the usual medications to which it previously
responded. OR Asthma symptoms are refractory to initial bronchodilator therapy in the emergency
department.
Often associated with patients who have underused or have been underprescribed anti-inflammatory
drugs.
5. INITIAL / IMMEDIATE MANAGEMENT

a. Give oxygen to keep SaO2 >92%


b. Inhaled 2-agonists (salbutamol / albuterol )
i) Via nebulizer:o
o
o
o
o

0.15mg/kg/dose (min. dose 1.25mg; max. dose 5mg.)


Or 2.5mg for <8yrs old & 5mg for 8yrs old.
Dilute to total of 2 - 3ml with 0.9% Normal saline
Repeat every 20 minutes for 3 doses
May nebulize back-to- back in severe cases

ii) Via Metered Dose Inhaler (MDI


100 200g (1 - 2 simultaneous puffs) repeated every 20 minutes with GOOD
inhaler technique or using a Spacer (alone if patient cooperates or with face mask
if available) for 3 doses.For each puff let patient breath through spacer 5 times
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before the next puff is administered.


Most patients respond within 1 hour of treatment.
iii)

Ipratropium 0.25 mg (or 2% solution) via nebulizer:


Ipratropium is synergistic with 2-agonists and should be administered with
salbutamol every 4-6 hours if available.
Note: Children appear to have more cholinergic receptors than adults and therefore are
more responsive to parasympathetic stimulation.

c. Start corticosteroids simultaneously with inhaled 2-agonists


Orally:
o Prednisolone /Methylprednisolone @1 -2mg/kg/day for 3 -5days OR
o Dexamethasone phosphate (decadron) @ 0.6mg/kg/day for 3days
Parentarely till oral tolerated:
IV Methylprednisolone 2mg/kg stat, then 0.5mg/kg/dose 6hrly OR
IM Dexamethasone 0.4mg/kg/dose BD (max. dose 16mg/day) OR
IV Hydrocortisone 4mg/kg/dose 6hrly
d. Intravenous Magnesium Sulfate in dose of 4075 mg/kg (typical dose 50mg/Kg, maximum
of 2g per dose) disolved in 3050 ml normal saline, infused over about 20 - 30 minutes could
be helpful for severe exacerbations not responding to conventional therapy.
6. CRITERIA FOR ADMISSION
If after nebulized bronchodilator therapy, child
Has not responded adequately clinically
Is exhausted
Still has a marked reduction in the predicted (or usual) peak flow rate
Has a reduced SaO2 <90%
Has status asthmaticus
o
o

CXR is indicated ONLY if there is severe dyspnoea or unusual features (e.g. asymmetry chest
signs suggestive of pneumothorax, lobar collapse) or signs of chest infection.
Blood gases indicated ONLY in life-threatening or refractory cases.

Respiratory failure and death may be precipitated by fatigued respiratory muscles. Hence, patients not
responding to treatment would require transfer to ICU for intubation and ventilatory support while
inhaled /parenteral bronchodilators and parenteral corticosteroids are administered.

7. SUBSEQUENT ACUTE MANAGEMENT

Continue with oxygen


Check hydration status and Rehydrate and/or maintain hydration
Continue nebulization therapy 1- 4hrly and space interval as tolerated.
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Additional nebulized bronchodilators may include ipratropium bromide 0.25mg nebulized with
salbutamol / albuterol
Monitor respiration, pulse, SaO2, PEFR & alertness.
Avoid drugs that aggravate asthma or depress respiration.(e.g. NSAIDS, Opiods)

Cilnical Features of Respiratory Failure


General

Respiratory

Cardiac

Neurologic

Fatigue

Wheezing

Bradycardia or

Restlessness

Sweating

Expiratory grunting
Decrease/Absent breath sounds
Flaring of the alae nasi

Excessive tachycardia
Hypotension or
Hypertension

Irritability
Headache
Confusion

Retractions of chest wall

Convulsions

Tachypnea, Bradypnea, or apnea

Coma

Cyanosis

On discharge (OUT-PATIENT MANAGEMENT OF ASTHMA):


o bronchodilator (preferable inhaled) short course oral steroid 5days
(see below for home-management)

OTHER DRUGS:
(If response to inhale 2-agonists not satisfactory or unable to cooperate with nebulization)
o Aminophylline (currently out of favour)
5mg/kg IV over 20-30min (omit if had any theophylline in the past 12hrs), then maintenance @ 0.8 1mg/kg/hr
o Adrenaline (1:1000)
0.01ml/kg SC (max. dose 0.3ml), may repeat every 20min up to 3 doses or
o Terbutaline
0.01mg/kg SC (max. dose 0.4mg), may repeat every 20min up to 3 doses

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(HOME/OUT-PATIENT MANAGEMENT OF ASTHMA):


o

Prevention of attacks/hospitalizations: Review periodically and treat:


Use PEFRs to monitor progress

Very occasional symptoms (once in several months):


Give short course (3-5 days) oral steroids with attacks
Inhaled bronchodilator as required

Frequent symptoms (more than one episode per month)


Daily Inhaled corticosteroids with bronchodilators
Adjust dose according to severity - The ultimate goal is to achieve a totally asthma-free status
Identify and counsel against precipitating factors

Note:
- Poor technique of using medications or adherence is often a cause of failed response to treatment
-Early intiation of steroids is useful in prevention severe attacks
-Exclude helminthiasis before administering high doses of steroids

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12.5.0 APPROACH TO PNEUMONIAS


Introduction

Commonly presents as acute onset of illness with cough, sometimes following acute
upper respiratory Illness (AURI).
Common features:
o Fever,
o Tachypnoea (fast breathing),
o Respiratory distress (Lower Chest In-drawing),
o Grunting
Evidence of area of consolidation on CXR (but not always)
Dullness, crepitations
Referred pain to abdomen suggests usually Right or Left lower lobe involvement
Presence of neck stiffness suggests Right upper lobe pneumonia
Abdominal distention may occur
Diagnosis not always easy: from mild febrile illness to peripheral circulatory collapse
with respiratory failure.
Lateral and AP X-rays are important for confirming diagnosis
Blood cultures are recommended for
o Severely ill
o Immunocompromised
o The malnourished
o Patients with other focus/foci of infection(s)
Sputum miscroscopy and culture useful if possible
Right Upper lobe pneumonias usually occur in first year of life from aspiration
Main Risk factors:
o Malnutrition,
o Low Birth Weight,
o Measles,
o Crowding,
o Smoke.

Aetiology: Common causes:




In developing:

Strept pneumoniae (pneumococcus): 30-50% cases

H. influenza (10-30% cases, more commonly in children <4 year)

There may be others that are less well known


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In young infants in developed countries:

Group B strept.,

Chlamydia trachomatis,

Listeria monocytogenes,

Strept faecalis,

Enteric gram negative bacilli - E. coli,

Klebsiella spp.

Treatment:
1st year:


Streptococcal, Staphylococcal, E. coli  chloramphenicol/ benzyl pen/ fluclox + gent (as first line)

Chlamydia trachealis  Erythromycin/Azithromycin

PS: Chlamydia pneumonia  dramatic X-ray changes in infants who are not that ill.

Beyond 1st year:




Pneumococcus (over 90%)  Amoxicillin /Co-AmoxiClav/Cefuroxime/


Co-trimoxazole if Pneumocystis jeroveci infection is suspected in the immune compromised

Remember Chlamydia, TB as important differentials

Any of these organisms may cause pneumonia in the malnourished or immunesuppressed, hence
appropriate treatment.

Oral treatment:
Amoxicillin,Co- AmoxiClav/Cefuroxime

Parenterral treatment:
Penicillin G, Co-AmoxiClav/Cefuroxime
Second line: Third generation cephalosporins
Choice of antibiotics ideally based on suspected organisms. For example, appropriate gram-negative
coverage should be considered in the immunocompromised.
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Special notes


Common complications:
Pleural effusions with pneumococcal infections

Empyemas, pneumothorax commonly with with staphylococcal infections

Suspect immunosuppression if there is a history of more than 2 episodes of pneumonia in one year

Notes during management:




Amoxicillin can effectively be given at 90mg/kg in 2 divided doses orally for 5 7 days, especially for
all patients who do not require admission.

Although septicaemic illness does not always occur it is helpful to do a blood culture at booking for
all hospitalized cases to facilitate choices for second line treatment, should the need arise.

Useful second line drugs:


Cefotaxime, Clindamycin, Azithromycin.

Need for hydration and nutritional support (look for and manage dehydration)

Effects of underlying/associated problems, e.g. measles, FB, AIDS, TB, etc

NB: Coughing + poor peripheral perfusion, rapid pulse, High resp. rate, cardiomegaly, Hepato(spleno)megaly is suggestive of Heart failure

12.6.0 ATYPICAL PNEUMONIAS


Definition:
Pneumonia caused by non-bacterial pathogens, typically Mycoplasma pneumoniae, Pneumocystis jeroveci,
viruses. Commonly associated with mild (progressive) symptoms (fever, cough) with chest X-rays that look
much worse than clinical picture would suggest.

Exclude TB
Always rule out immunosuppression in such cases.
Consider Erythromycin/Azithromycin or Co-trimoxazole for treatment in such cases depending on
history and other clinical parameters.

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12.7.0 PAEDIATRIC PULMONARY TUBERCULOSIS


Definition
Disease causes by mycobacterium tuberculosis; mycobacterium bovis; mycobacterium africanus. There are
two types namely pulmonary and extra pulmonary tuberculosis. Examples of extra pulmonary tuberculosis
includes CNS, Cervical, Spinal (Potts disease), abdominal tuberculosis and so forth.
Symptoms & Signs
Cough which is usually more than two (2) weeks; fever (may or may not be present at presentation), weight
loss, spinal mass; abdominal mass
Weight loss; Clubbing; Generalised Lymphadenopathy; Radiological changes; Gibbus
Diagnosis
Definitive: Sputum for AFBs (uncommon); PCR of urine and pleuritic fluid; Histopathology of biopsy
Supportive: Positive Family history; Radiological changes; Positive Mantoux test (>10mm); raised ESR
Specific treatment
Category 3 Children under 12 years regimen
Regimen

Initial phase (2 months)

Continuation (4 months)

2 months RH and Z
Daily 56 total doses

4 months RH
Daily 112 total doses

Patients

HR (Isoniazid 30mg+

HR (Isoniazid 30 mg

Weight

Rifampicin 60mg) +

and Rifampicin 60 mg)

Pyrazinamide (Z) 150mg +


Calculate to nearest number of childrens
tablets;

for 4 months
Calculate to nearest number of
childrens tablets;

H 5 mg/kg and

H. 5 mg/kg and

R 10 mg/kg daily, plus

R. 10 mg/kg daily

Up to 9 kg
According to
weight

Z (Pyrazinamide) 25 mg/kg
10 14 kg

HR 2 tablets + Z 2 tablets

HR 2 tablets

15 19 kg

HR 3 tablets + Z 3 tablets

HR 3 tablets

20 29 kg

HR 4 tablets + Z 4 tablets

HR 4 tablets

30+ kg

Refer to adult regimen BELOW

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Category 1 New adult (> 12 years)


A new case is a patient who has not taken TB drugs before, or has taken less than 4 weeks of TB drugs in
the past, (or a patient who has interrupted treatment of more than 4 weeks but is found sputum or culture
negative).
Regimen

Patients
Weight

Initial phase (2 months)

Continuation Phase (4 months)

2(RHZE)

4(HR)

Daily

Daily
112 total doses

56 total doses
(Isoniazid 75mg+

(Isoniazid 150mg +

Rifampicin 150mg +

Rifampicin 150mg)

Pyrazinamide 400mg +

For 4months

Ethambutol 275mg)
30-39 kg

1.5

40-54 kg

55-70 kg

70 kg +

The above are for the combination HRZE supplied through the Global TB Drug Facility.

RH: isoniazid +rifampicin; Z: pyrazinamide


*Tb Meningitis add streptomycin (20-40mg/kg/day
*Indication for steroids: Large Pleural effusion; Endobronchial tuberculosis; pericardial effusion; tuberculous
meningitis; Laryngeal tuberculosis
*Ethambutal should be considered with caution when there is treatment failure
SUPPORTIVE THERAPY
Improve Nutrition
Screening of immediate family members
Surgical intervention where necessary
POST EXPOSURE PROPHYLACTICS
For children five years and below with positive family contact Isoniazid 5mk/kg/day for three months
If mantoux is positive after three months continue prophylactics for another three months.
Start full treatment anytime you suspect disease

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13.0 MISCELLANEOUS DISORDERS


13.1.0 SNAKE BITES
Venomous snakes constitute approximately <15% of species of snakes known to exist.
13.1.1 RECOGNITION OF VENOMOUS SNAKES

Cytotoxic (local tissue destruction).


Viperidae (e.g. Puff adder, Gaboon viper)
-flat, arrow-shaped head
-short and stout body
-often lie in Z position
Neurotoxic (neuromuscular paralysis)
Elapidae (e.g. Mamba, Cobra)
-head continuous with body
-slender and agile
-hooded neck; spits
Haemotoxic (bleeding diathesis)
Colubrids and some vipers (e.g. carpet viper-Echis carinatus)
-very large eyes
-slender body
-ragged deep wound
Cardiotoxic(cardiac arrhythmias, hypotension etc)
-Viperidae
Myotoxic (systemic rhabdomyolysis)
-Hydrophiidae

13.1.2 CLINICAL FEATURES

Local pain and fang marks are very variable and of no help in diagnosis.
a.
Neurotoxicity
Typically, symptoms develop within 1-2 hours
Contraction of frontalis muscle (puckered forehead)
Extra-ocular muscles paralysis (e.g. opthalmoplegia, ptosis, blurred vision)
hyperacusis, hypersalivation, congested conjuctiva, circum-oral numbness
More serious late signs include dysphagia,dysphonia, and paralysis of muscles of deglutition and
respiration
NB. The paralysed tongue (inability to protrude ) may obstruct the upper airway.

b.

Haemotoxic (Procoagulant and haemorrhagin )


Persistent bleeding from fang mark, venopuncture site or new scarification marks
Spontaneous bleeding (e.g. gingival sulci, haematuria, intraperitoneal, GI tract)
Severe headache, meningism suggestive of Subarachnoid Haemorrhage
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Convulsion, hemiplegia and coma suggestive of intracranial haemorrhage


Shock and pulmonary oedema from haemorrhage and /or carpillary leakage.

Cytotoxic
-Blisters, tender swelling spreads from site of bite
-Early tender enlargement of lymph nodes draining the bitten site.
-Tensely swollen limbs are at risk of compartment syndrome

d.

Myotoxicity
-Muscle pain and stiffness with trismus
-Respiratory muscle paralysis
-Myoglobinuria and hyperkalaemia

Cardiotoxicity
Cardiac arrhymias, ECG abnormalities and hypotension
Responds rapidly to intravenous antivenom

e.

13.1.3 MANAGEMENT

i)
ii)
iii)
iv)

v)
vi)
vii)

general measures to support vital functions (including Airway, Breathing & IV fluids)
the site should be cleansed and then left strictly alone
Sedatives are required if the patient is apprehensive
Lab. Investigation:
o Look for evidence of blood in urine, stool & vomitus
o FBC (neutrophil >20,000/mm3,thrombocytopenia in severe envenoming)
o Incoagulable blood (leave 2-5mls of blood in dry glass: failure to clot in 20min)
o Raised CPK, AST, BUN in severe envenoming
o Do BUN, creatinine, serum K+ in ALL oliguric patients
o CXR for suspected pulmonary oedema
Appropriate antitetanus prophylaxis
Treat / prevent secondary infection (e.g. using Penicillin & metronidazole)
Antivenom if indicated* (see below)

13.1.4 INDICATION FOR ANTIVENOM

Severe local envenoming:


-swelling involving more than half the bitten limb or develop extensive blistering
Systemic envenoming:
-Neurotoxicity
-Haemotoxicity (see above)
-Impaired consciousness -Cardiotoxicity (cardiac arrhythmias, abnormal ECG, hypotension)
-Myotoxicity (Rhabdomyolysis stiff and tender muscles, trismus, myoglobinuria)
Local envenoming however small it may be plus
-vomiting in the absence of emetic mixture (herbal or orthodox) ingestion
-neutrophil leucocytosis
-elevated serum enzymes (CPK & AST)
-haemoconcerntration (elevated PCV)
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-uraemia
-oliguria ( urine output <0.5ml/kg/hour )

Confirmed case of elapid (cobra, mamba):


-do not wait for symptoms
-evidence of fang penetration and snake must definitely have been an elapid.

13.1.5 ADMINISTRATION OF ANTIVENOM

As soon as possible when ever indicated


The dosage is the same for adults and children; antivenom is for treating the amount of venom
and not size of patient.
IV route preferable to IM
Dosage
40ml in 200ml Normal saline IV stat, for adder/viper bite
60-80ml in 200ml Normal saline IV stat, for elapid (neurotoxin) bite
Run few drops initially as Test dose for serum sensitivity and look out for reaction, if no
reaction then whole drip in 1hr.
Repeat dose of antivenom if signs & symptoms of envenoming persist after 1st dose;
-persistence of cardiopulmonary signs > 30min after 1st dose
-persistence of incoaguable blood > 6hrs after 1st dose
Have drugs to counter anaphylaxis drawn up prior to giving antivenom (i.e. adrenaline,
antihistamine, corticosteroid )
Dilute 1 amp antivenom in 9 parts water for rinsing of venom from eyes (e.g. cobra)
Use specific antivenom for sea-snake or boomslang bites

NOTE:a) Fixed dilated pupils with paralysis may occur in cobra and mamba bites
b) The carpet viper (Echis carinatus) accounts for more snake bite morbidity and mortality than any
other species; and in Northern Ghana the same species is responsible for 86 bites per 100,000
populations with 28% mortality.

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13.2.0 POISONING IN CHILDREN


Poisoning in children may be:
Accidental
-the vast majority, especially <5years
Non-accidental -as a form of child abuse in children over 6 years
Deliberate self-poisoning -in older children
Iatrogenic
A. ASSESSMENT

a. History

High index of suspicion:


o Abrupt onset of symptoms
o Inconsistent history
o Previous history of ingestion
o Consider possibility of poisoning in any child with unexplained coma, seizures, or affective
disorder
Identification of toxins with details of ingestion
o Type and time of ingestion/exposure and maximum possible quantity of toxin
ingested/exposed.
Consider other causes of coma in the unconscious child e.g. trauma, seizures, CNS infection

Toxicity
Low
Intermediate
High

Potential toxicity in accidental poisoning in children


Medicine
Household products
Oral contraceptives
Chalk & crayons
Most antibiotics
washing powder
Paracetamol elixir
Bleach, disinfectants,
Salbutamol
window cleaners
Alcoholic drinks, iron
Acids, alkalis, petroleum distillates
Salicylate, digoxin
organophosphorus insecticides
Tricyclic antidepressants

B. EXAMINATION
Neuromuscular:
Vital signs:
Neuromuscular:
Ophthalmologic :
Skin:
Breath odors:
Gastrointestinal tract:

Ataxia Delirium/psychosis; Convulsions/seizures


Pulse; Respiration; Blood pressure; Temperature
Ataxia Delirium/Psychosis; Convulsions/Seizures; Paralysis; Coma
Pupil size; Nystagmus
Jaundice; Cyanosis; Urticaria; Hot dry; Flushing
Alcohol; Garlic; Acetone; Coal gas
Ileus; Violet emesis; Urinary retention

C. MANAGEMENT
Priorities
I.
Resuscitation; maintain the airway, breathing, and circulation.
Determine the type and severity of ingestion; utilizing the history, physical examination &
II.
laboratory analysis
Prevent further toxicity by removing the toxin or decreasing its absorption
III.
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Enhance the elimination of the drug and its metabolites


Continue assessment of vital signs
i)
Administer an antidote if possible
ii)
iii)
Rule out attempted suicide or child abuse

The comatose child


Maintain adequacy of airway and ventilation
i)
Start an intravenous line, give 10% dextrose containing fluid @ 5ml/kg for documented or
ii)
suspected hypoglycaemia. If effective continue fluid at maintenance rate.
iii)
Give naxolone 0.1mg/kg for documented or suspected opiate over dose.
iv)
Poor perfusion or circulatory compromise should be treated with IV infusion of 10ml/kg of
normal saline or Ringers lactate, repeated prn till childs condition stable (60ml/kg).
Obtain samples for toxicology (i.e. urine, blood, gastric aspirate)
v)

Surface decontamination
Remove clothing and wash skin with soap and water
Wash eyes with water or normal saline

Gastrointestinal decontamination
Note: Airway protection is of prime importance in gastrointestinal (GI) decontamination procedures.
Insertion of cuffed endotracheal tube is important in patients with altered sensorium or depressed gag
reflex, especially in those undergoing gastric lavage.
Activated charcoal
1g/kg body weight (or 10g / g ingested drug) PO or NG tube (50g).
contraindications
i. increased risk of aspiration e.g. Ileus, intestinal obstruction, hydrocarbons,
absent gag reflex.
ii. Alcohols, iron, caustics, lithium, electrolyte solutions, boric acid.
Gastric lavage
Indications:

Contraindications:

gastric lavage with large-bore tube may be useful in a life-threatening


ingestion and/or obtunded who arrive soon (90mins.)
caustic or hydrocarbon ingestions, co-ingestion of sharps.

Ipecac (Not recommended for use in hospital set up)


6 - 12month-old:
10ml followed by 10ml/kg water
1 - 5 years old:
15ml followed by 120ml water
>5 years old:
30ml followed by 200-300ml water
Contraindication:
Coma, Convulsions, Caustics, and hydroCarbon

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Cathartics (Avoid in children < 4years)


70% sorbitol solution at 1-2ml/kg
Magnesium citrate at 4-6ml/kg (max. 200ml)
Magnesium sulphate at 250mg/kg
Whole bowel irrigation
Polyethylene glycol solution @ 500ml/hr for 4-6hrs. Start slowly.
Dosage for adolescent is 1L/hr for 4-6hrs.
Effective and method of choice for symptomatic iron toxicity
Enhanced elimination
pH alteration to enhance excretion of weak acids and bases.
Sodium bicarbonate for alkalinization of urine (e.g. salicylates )
Ammonium chloride for acidification of urine, limited value.
Haemodialysis
Specific antidotes or therapy
Available for only a limited number of poisons.
e.g. N-acetylctsteine for acetaminophen (paracetamol).
Social assessment
To prevent further poisoning or accidents.

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13.3.0 SPECIFIC POISONING

13.3.1 HYDROCARBONS

Agents :

Gasoline, kerosene, lubricating oils, mineral oil


Benzene, turpentine, toluene, camphor
Carbon tetrachloride, methylene chloride, trichloroethane.

Assessment
Pulmonary: tachypnea, dyspnea, tachycardia, cyanosis, grunting, cough.
CNS:
lethargy, seizures, coma.
Hepatic toxicity: Acute liver failure
Cardiac toxicity: Arrhythmias.
Management
a.)

Decontamination
i)
Avoid emesis or lavage because of the risk of aspiration
Avoid charcoal unless there is co-ingestion. It does not bind aliphatics and
ii)
will increase the risk of aspiration.
iii)
If toxic amount ingested or contains potentially toxic substance, consider
INTUBATION WITH A CUFFED EndoTrachealTube followed by lavage.

b.)

If patient seen within 2hr, consider single dose of liquid paraffin


to decrease absorption. Give 10-15ml stat orally.

c.)

Treat pnuemonitis with oxygen.


Routine use of antibiotics and steroids not warranted.
Add antibiotics only with aspiration or suspected superimposed bacterial
infection.

d.)

Observe patient for at least 6 hours.


If asymptomatic for 6hrs and CXR is normal, discharge.
i)
If symptomatic within 6hrs, admit.
ii)
iii)
If asymptomatic but abnormal CXR, observe further.
Lung complication may be delayed 12 hrs.
iv)

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13.3.2 CAUSTIC INGESTIONS

Agents:
Strong acids
Alkalis (e.g. hair relaxers, drain/oven cleaners, detergent crystals )
Have the
potential for airway swelling or esophageal perforation, even if no symptoms initially or no
oropharyngeal burns.
Assessment
Drooling, persistent salivation, vomiting (often with blood or tissue)
aphonia, hoarseness, chest pain, abdominal pain.

stridor, dyspnea,

Management
a) Ipecac or lavage is contraindicated
b) Asymptomatic
ingested GI irritants but non caustic substance (e.g. household bleach) and
demonstrate good oral intake. Give oral fluids as a diluent (10-15ml/kg of
water, milk, etc.). may be followed as outpatients.
c) Symptomatic
Stabilize airway
i)
ii)
Maintain NPO. Do not pass NG tube BLINDLY
Obtain IV access and start IV fluids
iii)
Obtain FBC, GXM, CXR
iv)
v)
Obtain surgical consultation; prepare for endoscopy.
vi)
Consider IV steroid, though controversial; (hydrocortisone at
4mg/kg q6hrly or dexamethasone at 0.4mg/kg/12hrly or
methylprednisolone at 2mg/kg/day divided Q6-8hr )

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13.3.3 IRON POISONING

Assessment
1st stage GI toxicity (30min ~ 6hrs):
Nausea, vomiting, diarrhea, abdominal pain, hematemesis, and malena. Rarely
shock, seiziures,and coma
2nd stage Latent period (6 ~ 24 hours):
Improvement and sometimes resolution of clinical symptoms.
3rd stage Systemic toxicity (6 ~ 48 hours) :
Shock ,seizures, cyanosis, lerthargy, coma, hypoglycaemia, metabolic acidosis,
coagulopathy associated with hepatic dysfunction and/or renal failure, and
death.
4th stage Late complications (4 ~ 8 weeks):
Stricture formation with pyloric or antral stenosis.

Management
i)
ii)
iii)

iv)

v)
vi)

Determine amount of iron ingested. Abdominal X-ray may be helpful as most


iron tablets are radio-opaque.
If dose of elemental iron < 20mg/kg, no treatment is needed.
For elemental iron 20 60mg/kg or ingestion of unknown amount, consider
gastric emptying & give 60ml milk after. If remain asymptomatic in first 6hrs, no
further treatment.
Consider gastric lavage if dose ingested >60mg/kg and/or presence of large
amount of tablets on radiograph. If iron tablets still present in stomach despite
lavage begin whole bowel irrigation, especially if abdominal. X-ray reveals iron
tablets distal to the pylorus.
Supportive care is the most important therapy. IV fluids, avoid hypovolemic
shock / acidemia. Maintain urine output >2ml/kg/hr.
Give deferoxamine IV at 15mg/kg/hr via continuous infusion in all cases of
serious poisoning (i.e. presence of significant clinical symptoms, positive abd. Xray with significant number of tablets.) up to a total of 80mg/kg/24h. Leave 5g
in 50ml water in the stomach after gastric lavage. Beware of hypotension!!!

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13.3.4 PESTICIDES

Common agents
Carbamates
Organophosphates
Organochloride

e.g. Carbaryl
e.g. Malathion, dimefox, diazirion, TEPP etc.
e.g. DDT, benzene hexachloride, lindane etc.

Assessments

Muscarinic:
Salivation, Lacrimation, Urination, Defecation, gastric Cramping, Emesis (SLUDGE);
brochorrhea, miosis.

Nicotinic:
Muscle fasciculations, tremor, weakness.

Central Nervous System (CNS):


Aagitation, seizures, coma.

Treatment
Decontamination
a. Remove clothing and wash skin with soap and water
b. Gastric lavage if poison swallowed
c. Avoid milk or oils as they enhance absorption
Aims to support respiration and circulation, to treat acetylcholinesterase
inhibition,
control/treat seizures and to prevent hypoglycaemia.
a. Atropine(causes tachycardia, pupils dilatation, reduces bronchorrhea) 0.025mg/kg (min.
dose 0.1mg & max. dose 1mg) Q15min till fully atropinized
b. Pralidoxime (reverse & prevents fasciculations,neuropathy& weakness 20-40mg/kg,
Q6hrly for 24-48hrs.
c. Control seizures with pharmacotherapy e.g. Diazepam.

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14.0 APPENDIX
DRUGS IV/IO INFUSIONS TABLE
Drug

Dobutamine

Dopamine

Dilution
200mg in
50ml
200mg in
250ml
200mg in
50ml
200mg in
250ml
1mg in 5ml
1mg in
10ml

Adrenaline
[Adrenaline]

NorAdrenaline
[Noradrenaline]

Midazolam

Mannitol

Hydralazine

1mg in
50ml
1mg in
250ml
1mg in
50ml
1mg in
250ml
5mg in
50ml
10mg in
50ml
15mg in
50ml
10%
20%
20mg in
2ml
20mg in
50ml
20mg in
250ml

Compatible
fluids

Concentration

Dosage
g/kg/min

ml/kg/hr
0.03 - 0.075ml/kg/hr

4,000g/ml
Normal saline
5% Dextrose

800g/ml

2-5 g/kg/min
(max. 20g/kg/min)

4,000g/ml
Normal saline
5% Dextrose

800g/ml

0.15 - 0.375ml/kg/hr
0.075 0.15ml/kg/hr

5-10g/kg/min
(max. 20g/kg/min)

0.375 0.75ml/kg/hr

Neb.
100g/ml
Normal saline
5% Dextrose

10g/kg stat q3-5min


20g/ml
4g/ml

0.3 0.9ml/kg/hr
0.1-0.3g/kg/min
(max. 1/kg/min)

20g/ml
Normal saline
5% Dextrose

4g/ml

200g/ml

0.05 0.1g/kg/min
(max. 2g/kg/min)

Normal Saline

400g/ml
80g/ml

159

0.75 1.5ml/kg/hr
0.24 - 1.2ml/kg/hr

0.4-2.0g/kg/min
(max. 4g/kg/min)

300g/ml
10g/100ml
20g/100ml

1.5 4.5ml/kg/hr
0.15 0.3ml/kg/hr

100g/ml
Normal saline
5% Dextrose

0.1ml/kg stat
q3-5min

0.12 - 0.6ml/kg/hr
0.08 - 0.4ml/kg/hr

0.25g 1g/Kg/dose
Q6-8hrly
100-500g/Kg IM/IV
Q4-6hrly
12.5-50g/Kg/hr
[max. 3mg/Kg/day or
60mg/day]

2.5 10ml/Kg/dose
1.25 5ml/Kg/dose

0.031-0.125ml/Kg/hr
[max. 7.5ml/Kg/day]
0.156-0.625ml/Kg/hr
[max. 37.5ml/kg/day]

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Adrenaline
Midazolam
+

Na Bicarbonate
NorAdrenaline
Hydralazine

x
x
x
x
x

Haemacel

Blood

Fresh
Frozen
Plasma

Water for
Injection

Ringers
Lactate

Dopamine

Normal
Saline

Dobutamine

Dextrose
Saline

Dextrose

DRUG COMPATIBILITY TABLE

x
x
x
x
x

DIGOXIN DIGITALIZATION AND MAINTENANCE DOSE TABLE


DIGOXIN DIGITALIZATION AND MAINTENANCE DOSES IN MICROGRAM/KG/24HR
Age
TDD(total digitalizing dose)
Maintenance dose
PO
IV/IM
PO
IV/IM
Preterm
20
15
5
3-4
Full term
30
20
8-10
6-8
<2yr
40-50
30-40
10-12
7.5-9
2-10yr
30-40
20-30
8-10
6-8
>10yr & <100kg
10-15
8-12
2.5-5
2-3

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USEFUL FORMULAES

SYSTOLIC BLOOD PRESSURE = (90 + 2[age in years]) mmHg

BODY SURFACE AREA (M2) =

[4 Weight (kg)] +7
90 + Weight (kg)

[Height (cm) Weight (kg) 3600]

[Weight (lb)/60] + 0.1

GLUCOSE (mg/kg/min) = (% Glucose in Solution) (Infusion rate per hour)


60 Weight (kg)

IV INFUSION:
mg Drug
100ml fluid

= 6 Desired dose(mcg/kg/min) Weight(kg)


Desired rate (ml/hr)

Desired rate (ml/hr)

= 6 Desired dose(mcg/kg/min) Weight(kg)


Drug Concentration(mg/dl)

OSMOLALITY (285 ~295mOsm/L)


=2[Na+] +

ESTIMATED GFR (ml/min/1.73m2)

Where K is:
40
49
49
60

Glucose(mg/dl)
18

K x Height (cm)
Serum Creatinine (mol/L)

for neonates and infants younger than 1 yr,


for children 1 12 years
for adolescent females, 13 21 years
for adolescent males, 13 21 years

161

BUN (mg/dl)
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RESPIRATORY AND HEART RATE REFERENCE FOR AGE


AGE

RESPIRATORY RATE (RR)/MIN

HEART RATE (HR)/MIN

2SD

1SD

Normal Range

2SD

1SD

Normal Range

Birth 3mths

10 - 80

20 70

30 60

40 - 230

65 - 205

90 - 180

3mthS 6mths

10 - 80

20 70

30 60

40 - 210

63 - 180

80 - 160

6mths 1yr

10 - 60

17 55

25 45

40 - 180

60 - 160

80 140

1y r 3yr

10 - 40

15 35

20 30

40 -165

58 145

75 - 130

6yrs

8 - 32

12 28

16 24

40 - 140

55 - 125

70 110

10yrs

8 26

10 24

14 20

30 - 120

45 - 105

60 - 90

ESTIMATING BODY SURFACE AREA


In children beyond the neonatal period, metabolic rate, renal clearance, and some other bodily functions
vary more closely with surface area than they do with weight. Boyd's self-adjusting power equation that
relates surface area to body weight alone is reliable
weight
BSA
weight
BSA
weight
BSA
2
2
kg
m
kg
m
kg
m2
0.7
1.0
1.6
2.0
2.6
3.0
3.6
4.0
4.5
5.0
5.5
6.0
7.0
8.0
9.0
10.0
11.0

0.07
0.10
0.14
0.16
0.19
0.21
0.24
0.26
0.28
0.30
0.33
0.35
0.38
0.42
0.46
0.49
0.53

12
13
14
15
16
17
18
19
20
22
24
26
28
30
32
34
36

0.56
0.59
0.62
0.65
0.68
0.71
0.74
0.77
0.79
0.85
0.90
0.95
1.00
1.05
1.09
1.14
1.19

162

38
40
42
44
46
48
50
52
54
56
58
60
65
70
75
80
90

1.23
1.27
1.32
1.36
1.40
1.44
1.48
1.52
1.56
1.60
1.63
1.67
1.76
1.85
1.94
2.03
2.19

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WHO WEIGHT-FOR-LENGTH REFERENCE TABLE (45 -86CM)

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WHO WEIGHT-FOR-LENGTH REFERENCE TABLE (87 -120CM)

164