PAEDS HEBHK

General rules
1. Review tds (before 8am/2pm/6pm),
mo round tds,
sp round am all cases, pm/on: cases with issues/new cases
2. Branula/ Blood taking 2 tries, then need to ask for help
3. I/o, u/o all cases
4. TCA POPC usually need white book

Ward
-Acute/ Respi/ Front/ PR
1. Iso/respi cube- wear apron, try not to bring bht inside
2. All new cases remember to get immunization, development, feeding hx and check ears and
tonsils

Daycare duties- (Sunday- Thursday)

usually thalassemia pt
1. Blood taking-
- fbc/rp/lft/gxm (20cc/kg)
- 4monthly serum ferritin
- 6 monthly infective screening (hepb&c/vdrl/hiv)
2. Check PC pre tx + blood tx consent
3. Review pt and d/w MO
- current condition
- tx pc
- rw/ endorse old medications
- yearly eye/hearing assessment (make sure already have TCA)
- yearly echo (10y/o and above) (make sure already have TCA)
- next tca daycare 4/52 with fbc rp lft gxm
- next ferritin 4mly /infective screen 6mly
- trace any pending ix

update all charts for the patient.

-thalassemia flow chart
-chelation therapy chart
-investigation chart
-growth chart

Clinic (Monday and Wednesday)

- SN will call 7b, only go down for blood taking/ in-out for urine collection

NICU
- Conva/ NNJ
1. Every morning please make sure standby bag is complete
2. Post call person, please help tp print AM rw/ trace ix
3. Remember to fill in Baby book, especially G6PD/CTSH.
4. If CTSH results not out pior discharge, add in tracer book and remember to trace.

Postnatal rw at 6B
Weekdays: 2x round, after am/pm rounds: 10am/ 2.30pm

Weekend: 1x round 6am depends on MO

Mo in charge : post call mo ward

1. Ask for PNR list (purple book), Steth baby, ophthalmoscope usually at trolley drawer
2. Change 'upon discharge', to paeds review,
3. Review with simple hx, newborn exam, vital signs
4. Write plan,
Normal: Allow Discharge to mother if bo,pu, g6pd normal
or if jaundiced, Tsb stat, to inform if above PL

- If Refer2 ortho/surg and blood taking, done by HO OnG.

- If POPC TCA, referral letter by us.
- Only PNR the babies in pnr book, don't need to fill up baby book

Special tests
1. IEM- Plasma amino acids, urine for organic acid, spot test (get from lab)
2. Ammonia
- edta (purple)
- fresh blood (meaning sample will transport to jb by 9am, better take by 8am)
- need to request to mlt biochem
- form: double copy, chop ttp
- transport in ice box
3. Lactate
- put in grey bottle, fresh sample
- form double copy, chop ttp
- transport in icebox

NEONATAL RESUSCITATION made easy by Dr Seow CK (MRCP UK)

Question need to ask before standby

term/preterm? How many weeks --(to prepare plastic wrap/warmer/need intubate or not - if
very Prem has risk of RDS)
dexa given or not? To estimate risk for intubation. Dexa given to prevent RDS. If not then prepare
survanta

-Estimate fetal weight

to estimate ETT size and laryngoscope
 00 very Prem /0 prem/ 1 term
ett <1000g 2.5, 1-2kg 3.0, 2-3kg 3.5, >3000g 4.0

-meconium stained
to decide whether need for meconium aspirator, direct suction.

-any other perinatal risk factor

mgso4, preeclampsia,iugr,gdm, prom, etc.

Upon go to LR.

1) Turn on warmer.
Put 2-3 clean clothes above warmer, 1 piece dekat bed warmer. Utk facilitate initial step.

2) Adjust neopuff machine.

Connect to 10-15L O2, connect T-piece.
set PIP 16 PEEP 6
PEEP- positive end expiratory pressure. Minimum pressure to maintain alveolar opened upon
expiration.
PIP- positive inspiratory pressure- amount of pressure given during inspiration / bagging.

3) Set suction.
suction 80-100mmHg
term, black suction. Purple, less small term.

4) Ambubag
make sure inflatable.

5) Meconium aspirator
make sure jgn buka dulu! Mahal tu. Kalau nak direct suction baru open.

When baby out!

Assess this three first whether baby need resuscitation or not

TERM/PRETERM, MUSCLE TONE, RESPIRATION & CRYING.

If any of above is abnormal, baby need resuscitation.

1) Put on warmer
2) Open airway tilt chin, slight extension
3) Dry and stimulate the baby (flick the baby). After initial dry, tukar kain dgn yg above warmer
tu.

Continue with suction.

Mouth before Nose (M before N)
Reassess whether need further resuscitation or not
any labored breathing? Persistent cyanosis? - if present to give supplemental oxygen kalau mildly
distress (free flow oxygen, consider CPAP if nasal flaring, deep subcoastal recession)
CPAP yg just letak neopuff no bagging given. (So just give PEEP je)

If baby apnea/ gasping/ HR less 100

to initiate PPV (2,3 bag)
1 cycle 30 seconds
Ideally ada dua orang. Sorg PPV sorg kita heart rate.
Report heart rate in 6 second. If dlm 6 second dah 10 heart beat, report as HR>100.

Then reassess after 1 cycle.

check for spontaneous breathing, sp02 picking up? HR>100.
If present breathing, HR >100, continue CPAP, discontinue PPV.
If HR<100/ no spontaneous breathing, continue PPV.
If HR<60, start chest compression and prepare intubation. Initiate '1 and 2 and 3 and
BAG'.

After 45-60 second reassess the heart rate.

If HR<60, continue chest compression and consider adrenaline.
if HR>60, discontinue Chest Compression.
If HR 60-100, continue PPV
If HR >100, discontinue PPV and give CPAP (if ada voluntary breathing

Preparation of adrenaline
1mg of adrenaline in 1cc ampoule (equivalent 1:1000)
Dilute in 10 cc syringe with NS.
Jadi 1:10000 dilution.

How to give?
IV line - 0.1cc/kg
ETT - 0.5-1.0cc/kg

How to set an IV line in resus baby?

Do umbilical catheterization. If in resuscitation setting guna ryles tube smallest size.
Masuk in umbilical vein until ada back flow.

If ada Meconium stain, check vigorous or not. If vigorous continue indirect suction. If not
vigorous, DO NOT STIMULATE. DO DIRECT SUCTION.

Off tag
Asthma
Neb salbutamol
< 2 year 2.5mg = 0.5cc
>2 years 5mg= 1 cc
Neb atrovent
< 5 year 250mcg= 1cc
> 5 year 500mcg= 2cc

MDI salbutamol
<6 y/o = 6 puff
>6 y/o = 12 puff

Per puff-6 flap

Febrile fit - lim n gee

Benign condition of Seizure associate with fever with no other evidence of intracranial pathology
or metabolic derangement

Explaination:
Occur 3m to 6yrs
Occur becuz our brain is like comp, when have fever, our brain heated that causes it to be
haywire.
So it can present as fitting.
It can recur but freq of recurrance will be decrease as child gets older.
It wont cause any growth pr developmental delay.

What to do?
Assess surrounding- ensure safe environment
Put child on LLP
Loosen tight clothing
Timing
Observe fit pattern - generalized or focal
Post seizure- post ictal drowsiness?

When to bring hosp?

- focal seizure
- Seizure >5mins
- Non febrile seizure
- >1 seizure in 1 fever episode

Medication
Diazepam x2
Mida / phenytoin
Phenobarbitone

Diazepam
More den 5mins- impending status
IV 0.2mg/kg max 10 mg
2mls = 10 mg
less den 2 years old cannot IV , have alcohol component which will cause arrthymia in children)

SUPPository 0.5mg/kg-
each supp 5mg (max 2)
*supp Looks like ravin enema
- if cannot give midazolam

Iv Phenytoin
20mg /kg

Iv mida
0.2mg/kg

Phenobarbitone
20mg/kg

AGE
10% dehydration
1000 x weight x percent of dehydration
E.g. ns 25cc/ kg/h ( 14/3/2020 ,345pm)

Bolus
20cc/kg NS run fast

Nsd5- GI losses
NS - Correction
HSD5 - maintenance

1mth to 6 mth 150cc/kg/h

6mth to 1 year 120cc/kg/h
More den 1 years holiday segar
1st 10kg 100cc/kg
2nd 10kg 50cc/kg
3rd 10 kg 20cc/kg

Medication

iv hydrocortisone
4mg/kg qid ( max 100mg)
1 bottle 100mg
Dilute with 10cc water for injection
1cc= 10 mg
5kg x 4mg= 20 mg = 2cc

Iv c penicillin- ikut dz
Tonsil - 25k u/kg QID
Pneumonia - 50k u
Meningitis -100k u

Oral penicillin = pecillin v

Oral prednisolone
1mg/kg max 40mg
1 pill 5mg
7kgx 1mg= 7mg

Syp pcm
15mg/kg QID
Supp 15mg/kg - we have 125mg or 250mg
1ml =24 mg
120/5

Penicillin V
15 mg/kg QID

ORS
10cc/kg
E.g. 7kg =70cc per purge
1 sachet + 250cc ( water) then give 70cc
Duration 4 hours

Febrile fit education

Time of fit start and end
put on Left lateral position
Loosen all thight clothes
If vomit or secretion wipe away, never put in things in mouth

When fit abort, calm child

Observe fitting , Post fitting

When have to come hospital

1.Fitting without fever
2. More den 5mins - impending status epilepticus
3. If fitting is focal seizure - only part of body
4. More den 2 fitting episodes within fever - scare become complex
- Simple seizure aborted less den 15mins , generalized and only 1 time
-Complex more den 15mins ,focal seizure , seizure with post ictal drowniess , more den 2 times
in one febrile episode
5. Post ictal drowniess

Fluticasone - controller 1 puff 125 mcg

Salbutamol - reliever 1 puff 100mcg

K+ infusion rate
K+(g)× 13.3 x infusion rate(drip) / weight x 500
If >0.2 central line
E.g. 1g KCL in IVD Hsd5 30cc
1×13×30/ 7×500 = 0.11mmol/kg/hr
Daily require 1-2mmol/day

Meningitis
Cefutaxime
Ceftriaxone
Meropenem
Penicillin

Iv c penicillin 125 mg = 5ml

Usually abx 125mg = 5ml

IV immunoglobulin 1 vial 3g