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BODY TEMPERATURE ABG ANTHROPOMETRIC MEASUREMENTS

Subnormal <36.6C pH: 7.35-7.45 HCO3: 22-26mEq/L IDEAL BODY WEIGHT


Normal 37.4C pCO2: 35-45 B.E.: +/- 2mEq/L
Subfebrile 35.7 38.0C pO2: 80-100 O2 sat: 97% Age Kilograms Pounds
Fever 38.0C
At Birth 3kg (Fil)
High fever >39.5C 7
3.35kg (Cau)
Hyperpyrexia >42.0C NORMAL LABORATORY VALUES 3-12 Age (mo) + 9 / 2 Age (mo) + 10 (F)
mo Age (mo) + 11 (C)
AGE HR (bpm) BP (mmHg) RR (cpm) NB Infant Child Adole 1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17
RBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2 7-12 y Age (y) x 7 5 / 2 Age (y) x 7 + 5
Preterm 120-170 55-75/35-45 40-70 F: 4.2-5.4
Term 120-160 65-85/45-55 30-60 WBC 9-30,000 6-17,500 5-10,000 6-10,000
0-3 mo 100-150 65-85/45-55 35-55 Given Birth Weight:
PMNs 61% 61% 60% 60%
3-6 mo 90-120 70-90/50-65 30-45 Age Using Birth Weight in Grams
Lymph 31% 32% 30% 30%
6-12 mo 80-120 80-100/55-65 25-40 Hgb 14-24 11-20 11-16 M: 14-18 < 6 mo Age (mo) x 600 + birth weight (gm)
1-3 yrs 70-110 90-105/55-70 20-30 F: 12-16 6-12 mo Age (mo) x 500 + birth weight (gm)
3-6 yrs 65-110 95-110/60-75 20-25 Hct 44-64% 35-49 31-46 M: 40-54
6-12 yrs 60-95 100-120/60-75 14-22 F: 37-47 Expected Body Weight (EBW):
12-17 yrs 55-85 110-135/65-85 12-18 Platelets 140-300 200-423 150-450 150-450 Term Age in days 10 x 20 + Birth Weight
Ret 2.6-6.5 0.5-3.1 0-2 0-2 Pre-Term Age in days 14 x 15 + Birth Weight
BP cuff should cover 2/3 of arm
-: SMALL cuff: falsely high BP
-: LARGE cuff: falsely low BP COUNT (%) Age of Infant Ideal Weight
4-5 months 2 x Birth Weight
BMI BT 1-5 min 1-6 1-6 1-6 1 year 3 x Birth Weight
CT 5-8 min 5-8 5-8 5-8 2 years 4 x Birth Weight
Asian Caucasian PTT 12-20sec 12-14 12-14 12-14
Underweight <18.5 <18.5 3 years 5 x Birth Weight
Normal 18.5 22.9 18.5 24.9 5 years 6 x Birth Weight
Overweight 23.0 25 29.9 7 years 7 x Birth Weight
at risk 23 24.9 10 years 10 x Birth Weight
Obese I 25 29.9 30 39.9
Obese II 30 >40

APGAR
LENGTH / HEIGHT
(50 cm) Age Transverse-AP 0 1 2
Inches Blue / Pink body/ Blue Completely
Diameter ratio A
Age Centimeters Inches At Birth 1.0 Transverse = AP Pale extremities pink
At Birth 50 20 1y 1.25 Transverse > AP P Absent Slow (<100) > 100
1y 75 30 6y 1.35 Transverse >>> AP Coughs,
(-)
2-12 mo Age x 6 + 77 Age x 2.5 + 30 G Grimaces Sneezes,
Response
Cries
FONTANELS (-) Some flexion / Active
A
Age Gain in 1st Year is ~ 25cm Movement extension movement
0-3 mo + 9 cm 3 cm per mo Appropriate size at birth: 2 x 2 cm (anterior) Good,
R Absent Slow / Irregular
Closes at: Anterior = 18 months, or as early strong cry
3-6 mo + 8 cm 2.67 per mo
6-9 mo + 5 cm 1.6 cm per mo as 9-12 months
8 10: Normal
Posterior = 6 8 weeks or
9-12 mo + 3 cm 1 cm per mo 4 7: Mild / Moderate Asphyxia
2 4 months
0 3: Severe asphyxia

HEAD CIRCUMFERENCE GCS


THORACIC INDEX
(33-38 cms) Function Infants/Young Older
TI = transverse chest diameter Eye 4- Spontaneous Spontaneous
Age Inches Centimeters AP diameter Opening 3- To speech To speech
At Birth 35 cm (13.8 in) 2- To pain To pain
< 4 mo + 2 in + 5.08cm Birth : 1.0 1- None None
(1/2 inches / mo) (1.27cm / mo) 1 year : 1.25 Verbal 5- Appropriate Oriented
5-12 mo + 2 in + 5.08cm 6 years : 1.35 4- Inconsolable Confused
(1/4 inches / mo) (0.635cm / mo) 3- Irritable Inappropriate
1-2 yrs + 1 inch 2.54 cm 2- Moans Incomprehensible
3-5 yrs + 1.5 in + 3.81cm 1- None None
(1/2 inches / year) (1.27cm / mo) Motor 6- Spontaneous Spontaneous
6-20 yrs + 1.5 in + 3.81cm 5- Localize pain Localize pain
(1/2 inches / year) (1.27cm / mo) 4- Withdraw Withdraw
3- Flexion Flexion
2- Extension Extension
1- None None

EXPANDED PROGRAM ON IMMUNIZATION ADVERSE REACTIONS FROM VACCINES

VACCINE AGE DOSE # ROUTE SITE INTERVAL BCG 1. Wheal small abscess ulceration healing / scar formation in
BCG-1 Birth 0.05mL 1 ID R- 12 wks
or 6 wks (NB) Deltoid 2. Deep abscess formation, indolent ulceration, glandular enlargement,
0.1mL suppurative lymphadenitis
(older) DPT 1. Fever, local soreness
DPT 6 wks 0.5mL 3 IM Upper 2. Convulsions, encephalitis / encephalopathy, permanent brain
Outer damage
thigh OPV Paralytic Polio
OPV 6 wks 2 drops 3 PO Mouth 4 wks HEPA B Local soreness
HEPA B 6 wks 0.5mL 3 IM Antero- 4 wks MEASLES 1. Fever & mild rash
lateral 2. Convulsions, encephalitis / encephalopathy, SSPE, death
thigh
MEASLES 9 mos 0.5mL 1 SC Outer 4 wks ACTIVE PASSIVE
upper BCG Diphtheria
arm DPT Tetanus
BCG-2 School entry 0.1mL 1 ID L- OPV Tetanus Ig
Deltoid Hep B Measles Ig
TetToxoid Childbearing 0.5mL 3 IM Deltoid 1 mo then Measles Rabies (HRIg)
Hib Hep A Ig
women 6-12 mos
MMR Hep B ig
Tetanus Toxoid Rubella Ig
Varicella
H.E.A.D.S.S.S. H.E.A.D.S.S.S. NUTRITION
Sexual activities Home Environment AGE WT. CAL CHON
Sexual orientation? With whom does the adolescent live? 0-5 mo 3-6 115 3.5
GF/BF? Typical date? Any recent changes in the living situation? 8-11 mo 7-9 110 3.0
Sexually active? When started? # of persons? How are things among siblings?
Contraceptives? Pregnancies? STDs? 1-2 y 10-12 110 2.5
Are parents employed? 3-6 y 14-18 90-100 2.0
Are there things in the family he/she wants to
Suicide/Depression 7-9 y 22-24 80-90 1.5
change?
Ever sad/tearful/unmotivated/hopeless? 10-12 y 28-32 70-80 1.5
Thought of hurting self/others? Employment and Education 13-15 y 36-44 55-65 1.5
Suicide plans? Currently at school? Favorite subjects? 16-19 y 48-55 45-50 1.2
Patient performing academically?
Safety Have been truant / expelled from school? TCR = Wt at p50 x calories
Use seatbelts/helmets? Problems with classmates/teachers? TCR = CHON X ABW
Enter into high risk situations? Currently employed?
Member of frat/sorority/orgs? Future education/employment goals? Total Caloric Intake : calories X amount of
Firearm at home? intake (oz)
Activities
What he/she does in spare time? Gastric Capacity : age in months + 2
F.R.I.C.H.M.O.N.D. Patient does for fun?
Whom does patient spend spare time? Gastric Emptying Time : 2-3 hours
Fluids Hobbies, interests, close friends?
Respiration 1:1 1:2
Infection Drugs Alacta Bonna
Cardiac Used tobacco/alcohol/steroids? Enfalac Nursoy
Hematologic Illicit drugs? Frequency? Amount? Lactogen Promil
Metabolic Affected daily activities? Lactum S-26
Output & Input [cc/kg/h] N: 1-2 Still using? Friends using/selling? Nan Similac
Neuro
Diet Nestogen SMA
Nutraminogen
Pelargon
Prosobee

THE SEVEN HABITS OF


HIGHLY EFFECTIVE PEOPLE
by Stephen R. Covey

Habit 1: Be Proactive
Habit 2: Begin with the end in mind
Habit 3: Put First Things First
Habit 4: Think Win-Win
Habit 5: Seek first to understand and
then to be understood
Habit 6: Synergize
Habit 7: Sharpen the saw

EXPECTED LA SALLIAN
GRADUATE ATTRIBUTES
(ELGA)

1. Competent & safe physicians


2. Ethical & socially responsible
Doctors / practitioners
3. Reflective lifelong learners
4. Effective communicators
5. Efficient & innovative managers
DIARRHEA ACUTE DIARRHEA (at least 3x BM in 24 hrs) ETIOLOGY of AGE

Chronic : >14 days, non-infectious causes 4 Major Mechanisms Bacteria Viruses


Persistent : >14 days, infectious cause Aeromonas Astroviruses
1. Poorly absorbed osmotically active substances in Bacillus cereus Caloviruses
lumen Campylobacter jejuni Norovirus
ORS vol. after each loose stool 1 day 2. Intestinal ion secretion (increased) or decreased Clostridium perfringens Enteric Adenovirus
absorption Clostridium difficile Rotavirus
<24 mo 5-100mL 500mL 3. Outpouring into the lumen of blood, mucus Escherichia coli Cytomegalovirus
2-10 y.o. 100-200mL 1000mL 4. Derangement of intestinal motility Plesiomonas shigelbides Herpes simplex virus
>10 y.o. As much as wanted 2000mL Salmonella
Shigella
Rotaviral AGE (vomiting first then diarrhea) Staphylococcus aureus
For severe dehydration / WHO hydration Ingestion of rotavirus rotavirus in intestinal villi Vibrio cholerae 01 & 0139
(fluid: PLR 100cc/kg) destruction of villi Vibrio parahaemolyticus
Yersinia enterocolitica
Age 30mL/kg 75mL/kg
(secretory diarrhea absorption secretion) AGE
<12 1H 5H Parasites
>12 30 mins 2H Balantidium coli
Assessment of dehydration (Skin Pinch Test) Blastocyctis hominis
Cryptosporidium
Patient in SHOCK (+) if > 2 seconds Giardia lamblia
no dehydration if skin tenting goes back
20-30cc/kg IV fast drip immediately
but in infants 10cc/kg IV (repeat if not stable) Amoeba Metronidazole
If responsive & stable 75/kg x 4-6 hours Ascariasis Al/mebendazole
Cholera Tetracyline
Shigella TMP/SMX (Cotri)
Salmonella Chloramphenicol

TREATMENT PLAN A TREATMENT PLAN C


4 Rules of Home Treatment Treat severe dehydration QUICKLY!
1. Give extra fluid (as much as the child will take) 1. Start IV fluid immediately
2. If the child can drink, give ORS by mouth while the
> Breastfeed frequently & longer at each feeding IV drip is being set up
> if the child is exclusively breastfed, give one or 3. Give 100mL/kg Lactated Ringers solution
more of the following in addition to breastmilk
ORS solution First give Then give
food based fluid (e.g. soup, rice, water) Age
30mL/kg in: 70mL/kg in:
clean water
Infants
1 hour* 5 hours
(<12mo)
How much fluid to be given in addition to the usual
fluid intake? Children
30 min* 2 hours
(12mo-5yrs)
Up to 2 years: 50-100 mL after each
loose stool
Repeat once if radial pulse is very weak or not
2 years or more: 140-200 mL detectable
:- give frequent small sips from a cup reassess the child every 15-30 min.
:- if the child vomits, wait for 10 min then if dehydration is not improving,
resume give IV fluid more rapidly
:- continue giving extra fluids until diarrhea
stops also give ORS (~5mL/kg/hr) as soon as the child
can drink [usually after 3-4 hours in infants; 1-2
2. Give Zinc supplements hours in children]

Up to 6 mo: 1 half tab per day for 10-14 days reassess after 6 hrs (infant) & 3 hrs (child)
6 months or more: 1 tab or 20mg
OD x 10-14 days

3. Continue feeding
4. Know when to return

TREATMENT PLAN B

Recommended amount of ORS over 4 hour period

Age up to: 4 mo 4 mo 12 mo 12 mo 2 yrs 2 yrs 5 yrs


Wt: <6kg 6-9.9kg 10-11.9kg 2-19kg
(mL) 200-400 400-700 700-900 900-1400

Use childs age only when weight is not known


Approximate amount of ORS (mL)

CHILDS WT (kg) x 25
if the child wants more ORS than shown, give more
give frequent small sips from a cup
if the child vomits, wait for 10 min then resume
continue breastfeeding whenever the child wants

AFTER 4 HOURS
reassess the child & classify dehydration status
select the appropriate plan to continue treatment
begin feeding the child while at the clinic
ORS

Glucolyte 60 Pedialyte 45 0r 90

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


-: for acute DHN secondary to GE or other forms -: prevention of DHN & to maintain normal
of diarrhea except CHOLERA. In burns, post- fluidelectrolyte balance in mild to moderate
surgery replacement or maintenance, mild-salt dehydration.
loosing syndrome, heat cramps and heat
exhaustion in adults. Glucose 45mEq Glucose 90mEq
Na: 20mEq Na: 20mEq
Glucose: Cl: Gluconate: K: 35mEq K: 80mEq
100mmol/L 50mmol/L 5mmol/L Citrate: 30mEq Citrate: 30mEq
Na: Mg: Dextrose: 20g Dextrose: 25g
60 mol/L 5mmol/L
K: Citrate:
20 mmol/L 10 mmol/L
Pedialyte mild 30
-: to supplement fluid & electrolyte loss due to
Hydrite active play, prolonged exposure, hot and humid
-: 2 tab in 200ml water or 10sachets in 1L water environment

Glucose: Cl: Glucose: Glucose: 30mEq Mg: 4mEq


111mmol/L 80mmol/L 11mml/L Na: 20mEq lactate: 20mEq
Na: HCO3: Na: K: 30mEq Ca: 4mEq
90 mmol/L 5mmol/L 90 mmol/L Energy:
K: K: 20kcal/ 100ml
20 mmol/L 20 mmol/L

ETIOLOGY OF PNEUMONIA

Bacterial
- Streptococcus pneumoniae
- Group B streptococci (neonates)
ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)

- Group A streptococci
- Mycoplasma pnemoniae (adolescents)
- Chlamydia trachomatis (infants)
- Mixed anearobes (aspiration pneumonia)
- Gram negative enteric (nosocomial pneumonia)

Viral
- Respiratory syncitial virus
- Parainfluenza type 1-3 (Croup)
- Influenza types A, B
- Adenovirus
- Metapneumovirus

Fungal
- Histoplasma capsulatum (bird, bat contact)
- Cryptococcus neoformans (bird contact)
Child Age 2months up to 5years

- Aspergillus sp. (immunosuppressed)


Young Infants < 2months old

- Mucormycosis (immunosuppressed)
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii (immunosuppressed,
HIV, steroids)

SMR GIRLS
LUDANS METHOD (HYDRATION THERAPY) Stage Pubic Hair Breasts
1 Preadolescent Preadolescent
MILD MODERATE SEVERE Sparse, lightly pigmented, straight, Breast & papilla elevated, as small
DEHYDRATION DEHYRATION DEHYDRATION 2
medial border of labia mound, areola diameter increased
< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg Breast & areola enlarged, no contour
3 Darker, beginning to curl, amount
> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg separation
D5 0.3% in st
1 hr: Plain LR 1st hr: Plain LR 4
Course, curly, abundant but amount < Areola & papilla formed secondary
6-8 hours Next 5-7 hrs: Next 5-7 hrs: adult mound
D5 0.3% in D5 0.3% in Adult, feminine triangle, spread to Mature, nipple projects, areola part of
5
5-7 hours 5-7 hours medial surface of thigh general breast contour

HOLIDAY-SEGAR METHOD (MAINTENANCE) SMR BOYS


Stage Pubic Hair Penis Testes
WEIGHT TOTAL FLUID REQUIREMENT 1 None Preadolescent Preadolescent
0 - 10 kg 100 mL / kg Scanty, long slightly Enlarged scrotum, pink
2 Slightly enlargement
11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg] pigmented texture altered
Darker, starts to curl, small
> 20 kg 1500 + [ 20 for each kg in excess of 20 kg] 3 Longer Larger
amount
Resembles adult type but
NOTE: Computed Value is in mL/day Larger, glans &
4 less in quantity, course, Larger, scrotum dark
Ex. 25kg child breadth in size
curly
Answer: 1500 + [100] = 1600cc/day Adult distribution, spread
5 Adult size Adult size
to medial surface of thigh
ATYPICAL PNEUMONIA
> 3-12 mo
-: extrpulmonary manifestations - RSV
-: low grade fever - Other respiratory viruses
-: patchy diffuse infiltrates - Streptococcus pneumoniae
-: poor response to Penicillin - Haemophilus influenzae (Type B)
-: negative sputum gram stain - C. trachomatis
- M. pneumoniae
- Group A Streptococcus
Etiologic Agents Grouped by Age
> 2-5 yrs

DENGUE PATHOPHYSIOLOGY
> Neonates (<1mo) - RSV
- GBS - Other respiratory viruses
- E. coli - Streptococcus pneumoniae
- other gram (-) bacilli - Haemophilus influenzae (Type B)
- Streptococcus pneumoniae - C. trachomatis
- Haemophilus influenza (Type B) - M. pneumoniae
- Group A Streptococcus
> 1-3 months - Staph aureus
* Febrile pneumonia
- RSV > 2-5 yrs
- Other respiratory viruses - Streptococcus pneumoniae
- Streptococcus pneumoniae - Haemophilus influenzae (Type B)
- Haemophilus influenza (Type B) - C. trachomatis
- M. pneumoniae
* Afebrile pneumonia - Group A Streptococcus
- Chlamydia trachomatis - Staph aureus
- Mycoplasma homilis
- CMV

DENGUE Dengue Fever Syndrome (DFS) Dengue Shock Syndrome

> MOT: mosquito bite (man as reservior) Biphasic fever (2-7 days) with 2 or more of the ff: Manifestations of DHF plus signs of circulatory failure
1. rapid & weak pulse
> Vector: Aedes aegypti 1. headache 2. narrow pulse pressure (<20mmHg)
2. myalgia or arthralgia 3. hypotension for age
> Factors affecting transmission: 3. retroorbital pain 4. cold, clammy skin & irritability / restlessness
- breeding sites, high human population density, 4. hemorrhagic manifestations
mobile viremic human beings [petechiae, purpura, (+) torniquet test]
5. leukopenia DANGER SIGNS OF DHF
> Age incidence peaks at 4-6 yrs
1. abdominal pain (intense & sustained)
> Incubation period: 4-6 days Dengue Hemorrhagic Fever (DHF) 2. persistent vomiting
3. abrupt change from fever to hypothermia
> Serotypes: 1. fever, persistently high grade (2-7 days) with sweating
- Type 2 most common 2. hemorrhagic manifestations 4. restlessness or somnolence
- Types 1& 3 - (+) torniquet test
- Type 4 least common but most severe - petechiae, ecchymoses, purpura
- bleeding from mucusa, GIT, puncture sites Grading of Dengue Hemorrhagic Fever
> Main pathophysiologic changes: - melena, hematemesis
a. increase in vascular permeability 3. Thrombocytopenia (< 100,000/mm3)
4. Hemoconcentration
extravasation of plasma - hematocrit >40% or rise of >20% from baseline
- hemoconcentration - a drop in >20% Hct (from baseline) following
- 3rd spacing of fluids volume replacement
- signs of plasma leakage
b. abnormal hemostasis [pleural effusion, ascites, hypoproteinemia]
- vasculopathy
- thrombocytopenia
- coagulopathy

MANAGEMENT OF DENGUE MANAGEMENT OF HEMORRHAGE

A. Vital Signs and Laboratory Monitoring


Monitor BP, Pulse Rate
We have to watch out for Shock (Hypotension)
Torniquet Test: SBP + DBP = mean BP for 5 mins.
2 URINARY TRACT INFECTION

if 20 petechial rash per sq. inch on antecubital fossa


(+) test Suggestive UTI:
- Pyuria: WBC 5/HPF or 10mm3
Hermans Rash: - Absence of pyuria doesnt rule out UTI
- usually appears after fever lysed - Pyuria can be present w/o UTI
- initially appears on the lower extremities
- not a common finding among dengue patients Presumptive UTI:
- an island of white in an ocean of red - (-) urine culture
- lower colony counts may be due to:
* overhydration
Recommended Guidelines for Transfusion: * recent bladder emptying
* previous antibiotic intake
Transfuse:
- PC < 100,000 with signs of bleeding Proven or Confirmed UTI:
- PC < 20,000 even if asymptomatic - (+) urine culture 100,000 cfu/mL urine of a single
- use FFP if without overt bleeding organism
- FWB in cases with overt bleeding or - multiple organisms in culture may indicate a
signs of hypovolemia contaminated sample

> if PT & PTT are abnormal: FFP


> if PTT only: cryprecipitate

3-7cc/kg/hr depending on the Hct (1st no.) level


(D5LR)
10-20cc/kg fast drip PLR - hypotension, narrow pulse
pressure fair pulse

Leukopenia in dengue: probable etiology is


Pseudomonas

therefore: give Meropenem or Ceftazidime

ACUTE GLOMERULONEPHRITIS RHEUMATIC FEVER TREATMENT OF RHEUMATIC FEVER

Complications of AGN JONES CRITERIA: A. Antibiotic Therapy


- CHF 2 to fluid overload - 10 days of Oral Penicillin or Erythromycin
- HPN encephalopathy A. Major Manifestations - IM Injection of Benzethine Penicillin
- ARF due to GFR - Carditis (50-60%)
- Polyarthritis (70%) *** NOTE: Sumapen = Oral Penicillin!
- Chorea (15-20%)
STAGES of AGN - Erythema Marginatum (3%) B. Anti-Inflammatory Therapy
- Oliguric phase [7-10days] complications sets in - Subcutaneous Nodules (1%)
- Diuretic phase [7-10days] recovery starts 1. Aspirin (if Arthritis, NOT Carditis)
- Convalescent phase [7-10days] patients are B. Minor Manifestations Acute: 100mg/kg/day in 4 doses x 3-5days
usually sent home - Arthralgia Then, 75mg/kg/day in 4 doses x 4 weeks
- Fever
- Laboratory Findings of: 2. Prednisone
Prognosis Acute Phase Reactants (ESR / CRP) 2mg/kg/day in 4 doses x 2-3weeks
- Gross hematuria 2-3 weeks Prolonged PR interval Then, 5mg/24hrs every 2-3 days
- Proteinuria 3-6 weeks
- C3 8-12 weeks C. PLUS Supporting Evidence of Antecedent
- microscopic hematuria 6-12 mo or Group-A Strep Infection
1-2 years - (+) Throat Culture or Rapid Strep-Ag Test PREVENTON
- HPN 4-6 weeks - Rising Strep-AB Test
A. Primary Prevention

> Hyperkalemia may be seen due to Na+ retention - 10 days of Oral Penicillin or Erythromycin
> Ca++ decreases in PSAGN - IM Injection of Benzethine Penicillin
> in ASO titer
- normal within 2 weeks
- peaks after 2 weeks
- more pronounced in pharyngeal infection
than in cutaneous

B. Secondary Prevention

C. Duration of Chemoprophylaxis
KAWASAKI DISEASE
TREATMENT SEIZURES
CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI Currently Recommended Protocol:
(ALL SHOULD BE PRESENT) > Seizures: sudden event caused by abrupt,
A. IV-Immunoglobulin uncontrolled, hypersynchronous
A) HIGH Grade Fever (>38.5 Rectally) PRESENT discharges of neurons
for AT LEAST 5-days without other Explanation 2g/kg Regimen Infusion EQUALLY Effective in
High Grade Fever of at least 5 days Prevention of Aneurysms and Superior to 4-day > Epilepsy: tendency for recurrent seizures that are
DOES NOT Respond to any kind of Antibiotic! Regimen with respect to Amelioration of Inflammation unprovoked by an immediate cause
as measured by days of
B) Presence of 4 of the 5 Criteria Fever, ESR, CRP, Platelet Count, Hgb, and Albumin > Status epilepticus: >30min or back-to-back
1. Bilateral CONGESTION of the Ocular Conjunctiva w/o return to baseline
(seen in 94%) NOTE: There is a TIME FRAME of 10 days
2. Changes of the Lips and Oral Cavity (At least ONE) > Etiology:
3. Changes of the Extremities (At least ONE) - V ascular : AVM, stroke, hemorrhage
4. Polymorphous Exanthem (92%) B. Aspirin - I nfections : meningitis, encephalitis
5. Cervical Adenopathy = Non-Suppurative Cervical - T raumatic :
Adenopathy (should be >1.5cm) in 42%) HIGH Dose ASA (80-100mg/kg/day divided q 6h) - A utoimmune : SLE, vasculitis, ADEM
should be given Initially in Conjunction with IV-IG - M etabolic : electrolyte imbalance
HARADA Criteria THEN - I diopathic : idiopathic epilepsy
- used to determine whether IVIg should be given Reduced to Low Dose Aspirin (3-5mg/kg/day) - N eoplastic : space occupying lesion
- assessed within 9 days from onset of illness AND - S tructural : cortical malformation,
1. WBC > 12,000 Continued until Cardiac Evaluation COMPLETED prior stroke
2. PC <350,000 (approximately 1-2 months AFTER Onset of Disease) - S yndrome : genetic disorder
3. CRP > 3+
4. Hct <35%
5. Albumin <3.5 g/dL
6. Age 12 months
7. Gender: male

IVIg is given if 4 of 7 are fulfilled


If < 4 with continuing acute symptoms,
risk score must be reassessed daily

TYPES OF SEIZURES CLASSIFICATION BY CAUSE SIMPLE FEBRILE SEIZURE

A. Partial Seizures (Focal / Local) A. Acute Symptomatic A. Criteria for an SFS


Simple Partial (shortly after an acute insult) < 15 minutes
Complex Partial (Partial Seizure + Infection Generalized-tonic-clonic
Impaired Consciousness) Hypoglycemia, low sodium, low calcium Fever > 100.4 rectal to 101 F (38 to 38.4 C)
Partial Seizures evolving to Tonic-Clonic Head trauma No recurrence in 24 hours
Convulsion Toxic ingestion No post-ictal neuro abnormalities (e.g. Todds
paresis)
B. Generalized Seizures B. Remote Symptomatic Most common 6 months to 5 years
Absence (Petit mal) Pre-existing brain abnormality or insult Normal development
Myoclonic Brain injury (head trauma, low oxygen) No CNS infection or prior afebrile seizures
Clonic Meningitis
Tonic Stroke B. Risk Factors
Tonic-Clonic Tumor Febrile seizure in 1st / 2nd degree relative
Atonic Developmental brain abnormality Neonatal nursery stay of >30 days
Developmental delay
C. Idiopathic Height of temperature
SIMPLE FEBRILE SEIZURE No history of preceding insult
vs. Likely genetic component C. Risk Factors for Epilepsy
COMPLEX FEBRILE SEIZURE (2 to 10% will go on to have epilepsy)
Developmental delay
Febrile Seizure: Complex FS (possibly > 1 complex feature)
A seizure in association with a febrile illness in the 5% > 30 mins => _ of all childhood status
absence of a CNS infection or acute electrolyte Family History of Epilepsy
imbalance in children older than 1 month of age Duration of fever
without prior afebrile seizures

BRONCHIAL ASTHMA (GINA GUIDELINES)

Controlled Partly Controlled Uncontrolled


Day
none > 2x per wk
symptoms
Limitation of
none any
activities
3 or more symptoms
Nocturnal Sx
none any of Partly Controlled
(awakening)
Asthma in any week
Need for
< 2x per wk > 2x per wk
reliever
Lung
normal < 80%
function
Exacerbation none > 1x per yr 1x / week
Clinical Features:
TUBERCULOSIS RESPIRATORY DISTRESS SYNDROME
(Hyaline Membrane Disease) 1. Tachypnea, nasal flaring, subcostal and intercostal
A. Pulmonary TB retractions, cyanosis, grunting
fully susceptible M. tuberculosis, o Male, preterm, low BW, maternal DM, & perinatal 2. Pallor from anemia,
no history of previous anti-TB drugs asphyxia peripheral vasoconstriction
low local persistence of primary resistance to 3. Onset within 6 hours of life
Isoniazid (H) o Corticosteroids: Peak severity 2-3 days
most successful method to induce fetal lung Recovery 72 hours
2HRZ OD then 4HR OD or 3x/wk DOT maturation
Administered 24-48 hours before delivery Retractions:
Microbial susceptibility unknown or initial drug decrease incidence of RDS o Due to (-) intrapleural pressure produced by
resistance suspected (e.g. cavitary) Most effective before 34 weeks AOG interaction b/w contraction of diaphragm & other
previous anti-TB use respiratory muscles and mechanical properties of
close contact w/ resistant source case or living o Microscopically: diffuse atelectasis, eosinophilic the lungs & chest wall
in high areas w/ high pulmonary resistance to membrane
H. Nasal flaring:
o Due to contraction of alae nasi muscles leading to
2HRZ + E/S OD, then 4 HR + E/S OD or Pathophysiology: marked reduction in nasal resistance
3x/week DOT
1. Impaired/delayed surfactant synthesis & secretion Grunting:
2. V/Q (ventilation/perfusion) imbalance due to o Expiration through partially closed vocal cords
B. Extrapulmonary TB deficiency of surfactant and decreased lung Initial expiration: glottis closed
Same in PTB compliance lungs w/ gas
3. Hypoxemia and systemic hypoperfusion inc. transpulmo P w/o airflow
For severe life threatening disease 4. Respiratory and metabolic acidosis Last part of expiration: gas expelled against
(e.g. miliary, meningitis, bone, etc) 5. Pulmonary vasoconstriction partially closed cords
6. Impaired endothelial &epithelial integrity
2HRZ + E/S OD, then 10HR + E/S OD or 7. Proteinous exudates Cyanosis:
3x/wk DOT 8. RDS o Central tongue & mnucosa (imp. Indicator of
impaired gas exchange); depends on
total amount of desaturated Hgb

UMBILICAL CATHERIZATION
NEWBORN RESUSCITATION Cathether length
Indications Standardize Graph
AIRWAY: open & clear Vascular access (UV) Perpedicular line from the tip of the shoulder to
Positioning Blood Pressure (UA) and blood gas monitoring in the umbilicus
Suctioning critically ill infants Measure length from Xiphoid to umbilicus and add
Endotracheal intubation (if necessary) 0.5 to 1cm.
Complications Birth weight regression formula
BREATHING is spontaneous or assisted Infection Low line : UA catheter in cm = BW + 7
Tactile stimulation (drying, rubbing) Bleeding High line : UA catheter = [3xBW] + 9
Positive-pressure ventilation Hemorrhage UV catheter length = [0.5xhigh line] + 1
Perforation of vessel
CIRCULATION of oxygenated blood is adequate Thrombosis w/ distal embolization Procedure
Chest compressions Ischemia or infarction of lower extremities, bowel Determine the length of the catheter
Medication and volume expansion or kidney Restrain infant and prep the area using sterile
Arrhythmia technique
Air embolus Flush catheter with sterile saline solution
Place umbilical tape around the cord. Cut cord
RESUSCITAION MEDICATIONS Cautions about 1.5-2cm from the skin.
Never for: Identify the blood vessels.
Omphalitis (1thin=vein, 2thick=artery)
Atropine 0.02 ml/k IM, IV, ET
Peritonitis Grasp the catheter 1cm from the tip. Insert into the
Bicarbonate 1-2 meq/k
Contraindicated in vein, aiming toward the feet.
Calcium 10 mg elem Ca/k slow IV NEC Secure the catheter
Calcium chloride 0.33/k (27 mg Ca/cc) Intestinal hypoperfusion Observe for possible complications
Calcium gluconate 1 cc/k (9 mg Ca/cc)
1g/k = 2 cc/k D50 Line Placement
Dextrose
4 cc/k D25 Arterial line
Epinephrine 0.01 cc/k IV, ET Low line
Tip lie above the bifurcation between L3 & L5
High line
Tip is above the diaphram between T6 & T9

BILIRUBIN

PRETERM:
mg/dl mmol/L
0-1 hr 1-6 17-100
1-2 d 6-8 100-140
3-5 d 10-12 170-200

TERM
mg/dl mmol/L
0-1 hr 2-6 34-100
1-2 d 6-7 100-120
3-5 d 4-12 70-200
1 mo <1 <17

KRAMERS CLASSIFICATION OF JAUNDICE

SERUM
ZONE JAUNDICE
BILIRUBIN
I Head & neck 6-8
Upper trunk
II 9-12
to umbilicus
Lower trunk
III 12-16
to thigh
Arms, legs,
IV 15
below
V Hands & feet 15
MKD COMPUTATION
LUMBAR PUNCTURE To diagnose other medical conditions such as:
viral and bacterial meningitis Wt x mkd x preparation [mg/mL] = mL per dose
the technique of using a needle to withdraw syphilis, a sexually transmitted disease
cerebrospinal fluid (CSF) from the spinal canal. bleeding around the brain and spinal cord e.g. 12kg x 10mg x 5ml = 5mL per dose
multiple sclerosis, (affects the myelin coating of 120mg
SPINE the nerve fibers of the brain and spinal cord)
spinal cord stops near L2 Guillain-Barr syndrome, (inflammation of the * If per day, divide total (mL) by the # of divided doses
lower lumbar spine (usually between L3-L4 or nerves)
L45) is preferable Dose x preparation x frequency = mkd
Complication weight
CSF Local pain
clear, watery liquid that protects the central Infection
nervous system from injury Bleeding Paracetamol Drops = Wt: move 1 decimal
cushions the brain from the surrounding bone. Spinal fluid leak point to the left
It contains: Hematoma (spinal subdural hematoma Age Wt
glucose (sugar) Spinal headache 1 10 kg
protein Acquired epidermal spinal cord tumor 2 12
white blood cells 3 14
Rate : 500ml/day or 0.35ml/min Caution & Contraindications 4 16
Range : 0.3-04 ml/min Increased ICP 5 18
Volume : 50ml (infants) Bleeding diasthesis 6 20
150ml (adults) Traumatic Tap
Overlying skin infection 1 drop = 1/20 mL
Indication Unstable patient 1 teaspoonful = 5 mL
to diagnose some malignancies (brain cancer and 1 tablespoonful = 15 mL
leukemia) 1 wineglassful = 60 mL = 2 ounces
to assess patients with certain psychiatric 1 glassful = 250 mL = 8 ounces
symptoms and conditions. 1 grain = 60 mg
for injecting chemotherapy directly into the CSF 1 pint = 500 mL
(intrathecal therapy) 1 quart = 1000 mL
1 ounce = 30 mL
1 Kg = 2.2 lbs
1 lb = 0.45359 Kg

Empirical dose
6 months tsp TID QID
Procedure 6 mos 2 yrs tsp
Apply local anesthetic cream (ideally) 2-6 1 tsp
Position the patient 6-9 1 tsp
Prepare the skin using sterile techniques 9-12 2 tsp
Anesthetize the area with lidocane
Puncture the skin in the midline just caudal to the
spinus process, angle cephalad toward the
umbilicus using a g23 needle
Collect the CSF for analysis

CSF Analysis
1. Gram stain, culture and sensitivity
2. Cell count, differential count
3. Chemistries sugar, protein
4. Special studies

After care
Cover the puncture site with a sterile bandage,
apply pressure packing.
Patients must remain lying down for 4-6 hours
NPO for 4 hrs

CLINICAL FEATURES
CLASSIFICATION BASED ON SEVERITY
RESPIRATORY
MILD MODERATE SEVERE
ARREST
PERSISTENT - talking
INTERMITTENT
MILD MODERATE SEVERE - INF: softer, - at rest
Affects daily Affects daily Limits daily shorter, cry, - INF: stops
- walking
Exacerbation Brief activity & activity & activity & Breathless difficulty feeding Imminent
- can lie down
sleep sleep sleep feeding - hunched
Day-time Sxs <1x/wk >1x/wk daily continuous - prefers forward
Nightime Sxs <2x/mo >2x/mo >1x/wk frequent sitting
PEFR >80% >80% 60 - <80% <60% Talks in sentences phrases words
PEFR VAR <20% 20 - 30% >30% >30% may be usually usually drowsy /
Alertness
FEV1 >80% >80% 60 - <80% <60% agitated agitated agitated confused
often >30
RR bradypnea
mins
Accessory
(+) thoracoabd
muscles & none (+) (+)
movement
retractions

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