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Guide from

Topnotch IM guide
Yellow Book
Common OB-Gyne Tickler
Compiled by Adrian Alcaraz
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
Table of Contents
Table of Contents ............................................................................... 3
OB-GYNE NOTES ........................................................................................ 9
Prenatal Clinic Visit ........................................................................... 10
Sides NOTEs ........................................................................................ 10
Direct to DR ....................................................................................... 11
Direct to DR (Preeclampsia - in labor) .......................................... 11
Cesarean Section ............................................................................. 12
Preeclampsia - not in labor............................................................. 13
Eclampsia .......................................................................................... 14
Post-Partum Orders (PPO) ............................................................... 15
Post-Partum Orders (PPO-Preeclampsia) ..................................... 16
Post D&C ............................................................................................ 17
Retained/Incarcerated Placenta .................................................. 18
Oligohydramnios .............................................................................. 19
Premature Rupture of Membrane ................................................. 20
Pre-term.............................................................................................. 21
Placenta Previa Preterm ................................................................. 22
Missed Abortion / Unembryonic pregnancy................................ 23
Threatened Abortion (Septic)......................................................... 24
Threatened Abortion (Non-septic) ................................................ 25
Imminent / Inevitable Abortion ...................................................... 26
Incomplete Abortion (Septic)......................................................... 27
Incomplete Abortion (Non-septic) ................................................ 28
Bowel Prep ......................................................................................... 29
INTERNAL MEDICINE NOTES .................................................................. 30
Infectious .................................................................................................. 31
Upper Respiratory Tract Infection .................................................. 32
Community-acquired Pneumonia................................................. 34
CAP – Low Risk .............................................................................. 35
CAP – Moderate Risk ................................................................... 35
CAP – High Risk ............................................................................. 36
Urinary Tract Infection ...................................................................... 38
Uncomplicated Cystitis................................................................ 39
Acute Uncomplicated Pyelonephritis ....................................... 39
Asymptomatic bacteriuria.......................................................... 41
Recurrent Urinary Tract Infection ............................................... 41
Complicated Urinary Tract Infection ......................................... 42
Catheter-associated UTI ............................................................. 43
Candiduria .................................................................................... 43
Dengue Fever ................................................................................... 44
Dengue Fever - Group A............................................................. 45
Dengue Fever - Group B ............................................................. 46
Dengue Fever - Group C ............................................................ 47
Typhoid Fever .................................................................................... 49
Leptospirosis....................................................................................... 51
Cardiology ............................................................................................... 54
Hypertension: Presentation ............................................................. 55
Hypertensive Urgency vs Emergency ....................................... 59
Angina and Acute Coronary Syndromes ..................................... 60
UAHR/NSTEMI/STEMI ..................................................................... 62
Chronic Stable Angina ................................................................ 66
Pulmonology ........................................................................................... 68
Asthma ............................................................................................... 69
Chronic Obstructive Pulmonary Disease ...................................... 72
Endocrinology ......................................................................................... 74
Diabetes Mellitus ............................................................................... 75
DM Emergency ............................................................................. 76
Sliding Scale Insulin Protocol ....................................................... 79
Insulin Regimens............................................................................ 80
DM – Outpatient ........................................................................... 82
Thyroid Disease ................................................................................. 85
Hyperthyroidism ............................................................................ 85
Hyperthyroidism - Out-patient .................................................... 88
Hypothyroidism ............................................................................. 89
Gastroenterology ................................................................................... 90
Peptic Ulcer Disease ........................................................................ 91
Gastroesophageal reflux disease .................................................. 93
Toxicology ................................................................................................ 94
General Principles of Management .............................................. 95
Alcohol Intoxication ......................................................................... 97
Alcohol Withdrawal ..................................................................... 99
Paracetamol ................................................................................... 100
Silver Jewelry Cleaner .................................................................... 102
Kerosene .......................................................................................... 103
Acids ................................................................................................. 105
Alkali ................................................................................................. 107
Organophosphate ......................................................................... 109
National Poison Control and Management Center ................. 111
PEDIATRICS NOTES ................................................................................ 112
History & Physical Examination ........................................................... 113
H.E.A.D.S.S.S. .................................................................................... 114
F.R.I.C.H.M.O.N.D ............................................................................ 115
Nutrition ............................................................................................ 115
Vital Sign........................................................................................... 116
Anthropometric Measurements ................................................... 116
APGAR Score .................................................................................. 119
Glasgow Come Scale (GCS) ........................................................ 120
Tanner Stages.................................................................................. 121
Immunization ......................................................................................... 125
Expanded Program on Immunization ......................................... 126
Adverse Reactions From Vaccines .............................................. 126
Type of Immunization ..................................................................... 127
Intravenous Fluid ................................................................................... 128
Selection of Fluids ....................................................................... 129
Holiday-Segar Formula .............................................................. 130
Alternative (Ludan’s Method) .................................................. 130
Conversion of microdrops (ugtts) to macrodrop (gtts) ........ 131
Pulmonology ......................................................................................... 132
Pneumonia in Children .................................................................. 133
Revised Risk Classification for Pneumonia .............................. 134
PCAP – D (Pneumonia-II, Pneumonia Very Severe)............. 135
PCAP - D with Acute Gastroenteritis ....................................... 137
PCAP-D with Hyper-reactive Airway Disease ....................... 139
PCAP-D with suspected PTB ..................................................... 142
PCAP-D with Malnutrition .......................................................... 145
PCAP – C (Pneumonia-I, Pneumonia Severe) ....................... 147
Tuberculosis in Children ................................................................. 149
Pleurisy .............................................................................................. 154
Consolidation (Lobar Pneumonia) ............................................. 159
Nosocomial Pneumonia ................................................................ 162
Laryngotracheobronchitis ............................................................. 165
Bronchial Asthma ........................................................................... 167
Stepwise Approach for Managing Asthma in Children ....... 176
Allergology............................................................................................. 178
Anaphylaxis ..................................................................................... 179
Gastroenterology ................................................................................. 184
Diarrheal Diseases .......................................................................... 185
Treatment Plan A ........................................................................ 187
Treatment Plan B ........................................................................ 188
Treatment Plan C ....................................................................... 189
Oresol ........................................................................................... 190
AGE with Hypovolemic Shock .................................................. 191
AGE with Severe Dehydration .................................................. 193
AGE with Some/Mild Dehydration ........................................... 195
Antibiotics used to treat Specific cause of diarrhea ............ 197
Adjunct management for diarrhea ........................................ 198
Infectious ................................................................................................ 199
Dengue Hemorrhagic Fever (DHF) .............................................. 200
Dengue without Warning Signs (DHF Grade I) ...................... 202
Dengue with Warning Signs (DHF Grade II) ........................... 204
Severe Dengue (DHF Grade III – Compensated Shock) .... 206
Recommended Fluid Therapy for Compensated Shock..... 208
Severe Dengue (DHF Grade IV – Hypotensive Shock) ........ 209
Recommended Fluid Therapy for Hypotensive Shock ......... 211
Interpreting Hematocrit Changes ........................................... 212
Management of Dengue ......................................................... 213
Summary of Blood Component Therapy ............................... 217
Typhoid Fever .................................................................................. 218
Bacterial Skin & Soft Tissue Infection ............................................ 220
Tetanus ............................................................................................. 222
Malaria ............................................................................................. 228
Meningococcemia ........................................................................ 232
Viral Exanthem ................................................................................ 235
Urinary Tract Infection (UTI) ........................................................... 237
Nephrology ............................................................................................ 240
Nephrotic Syndrome (NS) ............................................................. 241
Acute Glomerulonephritis (AGN) ................................................. 243
Neonatology ......................................................................................... 245
Ballard Score ................................................................................... 246
Problems in the neonates ............................................................. 247
Neonatal Resuscitation Program ............................................. 248
Essential Intrapartum Neonatal Cure (EINC).......................... 255
S.T.A.B.L.E ..................................................................................... 265
Neonatal Pneumonia .................................................................... 268
Nosocomial Pneumonia/ Infection ............................................. 269
Neonatal Sepsis .............................................................................. 270
Potentially Septic Newborn (PSNB) .............................................. 273
Meconium Aspiration Syndrome (MAS) ...................................... 274
Neonatal Jaundice ........................................................................ 276
Omphalitis ........................................................................................ 279
Perinatal Asphyxia .......................................................................... 280
Prematurity ...................................................................................... 283
For ≥ 34 weeks AOG ................................................................... 284
For < 34 weeks AOG .................................................................. 285
Necrotizing Enterocolitis (NEC) ..................................................... 286
Neonate Hematocrit ≥ 0.65 .......................................................... 288
Well Baby ......................................................................................... 290
Well Baby, Term, AGA, NSVD.................................................... 290
Well Baby, Term, AGA, Cesarean Section ............................. 290
Well Baby, Term, SGA (>2kg) or LGA (>3.7kg) ....................... 291
Well Baby, Term, SGA (<2kg) .................................................... 292
Neurology .............................................................................................. 293
CNS Infections ................................................................................. 294
Suppurative/Bacterial Meningitis ............................................. 297
TB Meningitis ................................................................................ 299
Viral Meningitis ............................................................................ 302
Brain Abscess .............................................................................. 304
Febrile Seizures ................................................................................ 306
Acute Symptomatic Seizure (ASS) ............................................... 309
Hematology........................................................................................... 311
Anemia............................................................................................. 312
Thalassemia/ Thalassemia Syndrome for Blood transfusion ..... 316
ORTHOPEDICS NOTES ........................................................................... 318
Adult < 40 years old........................................................................ 319
Adult ≥ 40 years old ........................................................................ 320
Pediatrics ......................................................................................... 321
MEDICATION .......................................................................................... 322
Computation of Drugs as Drip (Pedia)........................................ 323
Preparation for Desired Dextrocity .............................................. 326
All about Drips (Adult) .................................................................... 327
Guideline to oral switch of antibiotic therapy ........................... 334
Suggested Conversion Regimens ................................................ 335
Common Pediatric Medicine Recommended Dose ............... 336
Cough/Cold Preparation.......................................................... 342
Emergency medicine for pediatrics........................................ 343
Other Drugs ..................................................................................... 344
Pain ............................................................................................... 344
Fever ............................................................................................. 345
Itchiness ....................................................................................... 345
Diaper Rash ................................................................................. 345
Teething ....................................................................................... 345
Decrease Appetite .................................................................... 345
Oral Sores ..................................................................................... 346
Frank Seizure................................................................................ 346
Vertigo ......................................................................................... 346
Impacted Cerumen................................................................... 346
Vomiting....................................................................................... 346
Tinnitus .......................................................................................... 346
Laxatives ...................................................................................... 347
Anti-diarrheals ............................................................................. 347
Ear Drops...................................................................................... 348
Topical Meds ............................................................................... 348
ELECTROLYTES ........................................................................................ 349
General Management Strategy .................................................. 350
Hypokalemia ................................................................................... 351
KCl computation ............................................................................ 352
KCl incorporation (maintenance) ........................................... 352
KCl correction ............................................................................. 353
Hypomagnesaemia ....................................................................... 355
Hypocalcaemia.............................................................................. 356
LABORATORY ......................................................................................... 357
Urinalysis ........................................................................................... 358
Urine Microscopy ........................................................................ 360
Clinical Syndromes of Renal Disease ...................................... 362
Nephrotic vs Nephritic Syndromes .......................................... 363
Serum Creatinine ........................................................................ 364
Normal Values (Pediatrics)............................................................ 368
OB-GYNE NOTES
Doctors’ Guide
Prenatal Clinic Visit
0 – 28 weeks - Monthly
28 – 36 weeks - every 2 weeks
> 36 weeks - weekly

Tetanus Toxoid
 TT1 – first contact or as early as possible in pregnancy
 TT2 – at least 4 weeks after TT1
 TT3 – at least 6 months after TT2
 TT4 – at least 1 year after TT3 or during the subsequent
pregnancy
 TT5 – at least 1 year after TT4 or during subsequent
pregnancy
Initial Laboratory
 CBC plt, CTBT, Blood typing
 UA
 HBsAg
 VDRL

Sides NOTEs
Date:
Time:
BP:
LMP:
AOG:
EDC:
FH:
FHT:
IE: Cervix: cm dilated; % effaced
( ) BOW; Station
Presentation:
Impression: G_P_ ( ); PU; ___weeks AOG by____; __IL

Ex: G1P0; PU; 37 1/7 weeks AOG by LMP; Cephalic


IL
Direct to DR
 Direct to DR
 Secure consent
 NPO
 Start IVF w/ D5LR 1L to run at 20 gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 Monitor FHT q15mins, record please
 Monitor VS q1hr
 Perineal prep please

Direct to DR (Preeclampsia - in labor)


 Direct to DR
 Secure consent
 NPO
 Start IVF w/ D5LR 1L to run at 20gtts/min
 SD with D5W 500cc +10g MgSO4 at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 FBS, BUN, Crea
 SPOT, SGPT
 Serum K
 CXR PA with abdominal shield - enroute to DR
 ECG 12 leads
 Baseline CTG
 MEDS:
 Hydralazine 5mg IVT PRN for BP ≥ 160/100mmHg
 MgSO4 4g IV bolus now
 Monitor FHT and VS q15 mins, record please
 Perineal prep please
 Refer accordingly
Cesarean Section
 Please direct to OB-OR
 Secure consent
 NPO
 Start IVF w/ D5LR 1L to run at 30gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 MEDS:
 Cefuroxime 1.5 g IVT ( ) ANST on call to OB-OR then
750 mg IVT q8h
 For (STAT or DIRECT) (Primary or Repeat) LTCS;
Indication: ______________
 Secure consent for LTCS
 Inform COC/SROC
 Inform OB-OR/Anes/Pedia ROD
 Perineal Prep please
 Monitor FHT q1hr, record please
 Monitor VS q4hrs, record please
 IF repeat LTCS
 Secure 1unit of PRBC properly typed &
crossmatched for possible OR use
 Refer accordingly

Indications for CS:


 CPD
 Breech primi
 Abruptio placenta
 Transverse presentation
 Twin – cephalic, breech
 Previous CS
 Uncontrolled BP
 Eclampsia
 Impending eclampsia
Preeclampsia - not in labor
 Please admit patient to ward
 Secure consent
 NPO temporarily, except meds
 Start IVF w/ D5LR 1L to run at 20gtts/min
 SD with D5W 500cc + 10g MgSO4 at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 FBS, BUN, Crea,
 SPOT, SGPT
 Serum K
 CXR PA with abdominal shield
 ECG 12 leads
 Baseline CTG
 MEDS:
 Hydralazine 5mg IVT PRN for BP ≥ 160/100mmHg
 Methyldopa 250mg TAB; 1 tab q6hr PO
 MgSO4 4g IV bolus now
 IF term
 HNBB 1amp IVT now then q1hr x 2 more doses
 Monitor FHT, VS and POL q2hrs, record please
 Insert FBC & attach to urobag
 I&O q1hr, record please
 Perineal prep please
 Refer accordingly
Eclampsia
Call ROD Immediately (Emergency measures:
O2 inhalation, tongue depressor, suction secretions)

 Please direct to OB-OR


 Secure consent
 NPO
 Start IVF w/ D5LR 1L to run at 20gtts/min
 SD with D5W 500cc + 10g MgSO4 at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 FBS, BUN, Crea, SPOT, SGPT Serum K
 CXR PA with abdominal shield
 ECG 12 leads
 MEDS:
 Hydralazine 5mg IVT PRN for BP ≥ 160/100mmHg
 MgSO4 4g IV bolus now
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 Insert FBC & attach to urobag
 Monitor FHT and VS q15mins, record please
 Monitor I&O q1hr, record please
 For direct to OR for LTCS for deteriorating maternal
status secondary to eclampsia
 Secure consent for LTCS
 Inform COC/SROC
 Inform OB-OR/Anes/Pedia ROD
 Refer accordingly
Post-Partum Orders (PPO)
 Oxytocin 10 IU IM now

 To ward
 DAT
 Incorporate Oxytocin to present IVF at 1:100 dilution to
run at 20 gtts/min then IVF to consume if no active
bleeding
 IVFTF : PLR 1L to run at 20 gtts/min
 MEDS:
 IF clear meconium
 Cefadroxil 500 mg CAP; 1 cap BID for 7 days
 IF thin meconium
 Cefuroxime 500 mg CAP; 1 cap BID for 7 days
 IF moderate to thick meconium
 Cefuroxime 500 mg CAP; 1 cap BID for 7 days
 Metronidazole 500 mg TAB; 1 tab TID for 7 days
 Mefenamic acid 500 mg TAB; 1 tab TID PRN for pain
 MV + Iron TAB; 1tab OD OR
 Ferrous sulfate + folic acid; 1 tab OD
 Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
 WOF profuse bleeding and other unusual events
 Refer accordingly
Post-Partum Orders (PPO-Preeclampsia)
 Oxytocin 10 IU IM now

 To ward
 DAT
 Incorporate Oxytocin to present IVF at 1:100 dilution to
run at 20 gtts/min then IVF to consume if no active
bleeding
 SD with D5W 500cc +10g MgSO4 at 20gtts/min
 MEDS:
 IF clear meconium
 Cefadroxil 500 mg CAP; 1 cap BID for 7 days
 IF thin meconium
 Cefuroxime 500 mg CAP; 1 cap BID for 7 days
 IF moderate to thick meconium
 Cefuroxime 500 mg CAP; 1 cap BID for 7 days
 Metronidazole 500 mg TAB; 1 tab TID for 7 days
 Mefenamic acid 500 mg TAB; 1 tab TID PRN for pain
 MV + Iron TAB; 1tab OD OR
 Ferrous sulfate + folic acid; 1 tab OD
 Amlodipine 10mg TAB; 1 tab OD at AM
 Losartan 50 mg TAB; 1 tab OD at HS
 Clonidine 75 mg TAB; 1 tab SL PRN for BP ≥160/100
mmHg
 Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
 Insert FBC
 I & O q4hr
 WOF profuse bleeding and other unusual events
 Refer accordingly
Post D&C
 Oxytocin 10 IU IM now

 To ward
 DAT once fully awake
 Incorporate Oxytocin to present IVF at 1:100 dilution to
run at 20 gtts/min then IVF to consume if no active
bleeding
 MEDS:
 Cefadroxil 500 mg CAP; 1 cap BID for 7 days; OR
 Clindamycin 500 mg CAP; 1 cap TID for 7 days
 Mefenamic acid 500 mg TAB; 1 tab TID PRN for pain
 MV + Iron TAB; 1tab OD
 Methylergonometrine 1amp IVT now then 1 tab TID x
3 days
 Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
 WOF profuse bleeding and other unusual events
 Refer accordingly
Retained/Incarcerated Placenta
 Please admit patient to ward
 Secure consent
 NPO temporarily
 Start IVF w/ D5LR 1L to run 200cc as fast drip then
incorporate oxytocin 1:100 dilution at 20 gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 MEDS:
 Cephalexin 500 mg TID x 7days; OR
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr
ANST ( )
 Metronidazole 500 mg IVT now then q8 hr
 Mefenamic acid 50 0mg TAB; 1 tab TID PRN for pain
 MV + Iron TAB; 1tab OD
 Methylergonometrine 1amp IVT now then 1 tab TID x
3 days
 Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
 WOF profuse bleeding and other unusual events
 Refer accordingly
Oligohydramnios
 Please admit patient to ward
 Secure consent
 DAT; NPO once in labor
 Start IVF w/ D5LR 1L to run 300cc as fast drip then
regulate at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 Pelvic UTZ
 MEDS:
 HNBB 1amp IVT now then q1hr x 2 more doses
 O2 inhalation via nasal cannula at 3-5LPM
 Position at left lateral decubitus
 Monitor VS, FHT & POL q2hr, record please
 Perineal prep please
 Refer accordingly
Premature Rupture of Membrane
 Please admit patient to ward
 Secure consent
 DAT; NPO once in labor
 Start IVF w/ D5LR 1L to run at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 MEDS:
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 IF term
 HNBB 1amp IVT now then q1hr x 2 more doses
 monitor FHT & POL q1hr, record please
 Monitor VS q4hr, record please
 Nipple stimulation
 Awaits vaginal delivery
 Perineal prep please
 Refer accordingly

Alternative for Cefuroxime:


 Penicillin G Na 5M U IVT q6 hrs ( ) ANST
 Ampicillin 2g IVT now then 1g IVT q6hr ( ) ANST
Pre-term
 Please admit patient to ward
 Secure consent
 NPO temporarily
 Start IVF w/ D5LR 1L to run 500cc as moderate fast drip
then regulate at 30gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 Pelvic UTZ
 MEDS:
 Isoxsuprine drip (SD but with no loading of mainline):
D5W 500cc + Isoxsuprine 4amps to run at
20ugtts/mins & increase titration 5ugtts/min q20mins
to a max of 60ugtts/min if there are ongoing uterine
activity or evidence of further cervical dilation; OR
 MgS04 drip (SD but with no loading of mainline):
D5W 1L + MgSO4 10mg to run at 20gtts/min
 IF 24-34wks AOG
 Dexamethasone 6mg IM now then q12hr x 3 more
doses
 Monitor FHT & POL q1hr, record please
 Monitor VS q4hr, record please
 Nipple stimulation
 Awaits vaginal delivery
 Perineal prep please
 Refer accordingly
Placenta Previa Preterm
 Please admit patient to ward
 Secure consent
 NPO temporarily
 Start IVF w/ D5LR 1L to run at 30gtts/min
 SD with D5W 500cc + 10g MgSO4 at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 MEDS:
 IF 24-34wks AOG
 Dexamethasone 6mg IM now then q12hr x 3 more
doses
 Secure 1unit of PRBC properly typed and
crossmatched
 WOF profuse vaginal bleeding
 CBR w/o BRP
 monitor FHT & VS q1hr, record please
 Perineal prep please
 Refer accordingly
Missed Abortion / Unembryonic pregnancy
 Please admit patient to ward
 Secure consent
 NPO
 Start IVF w/ D5LR 1L to run at 30gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 MEDS:
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 HNBB 1amp IVTT now then q1 hr x 2 more doses
 Monitor VS q4 hrs, record please
 WOF profuse bleeding or passage of products of
conception
 For D&C on call
 Refer accordingly
Threatened Abortion (Septic)
 Please admit patient to ward
 Secure consent
 Low residue diet
 Start IVF w/ D5LR 1L to run at 30gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 CXR PA with abdominal shield
 Blood & urine GS/CS
 Gram stain of vaginal discharge
 IF ≤2 weeks
 TVS UTZ
 MEDS:
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 Metronidazole 500 mg IVT now then q8 hr
 Paracetamol 300mg IVT q 4hrs PRN for fever > 37.8
 CBR without BRP
 Perineal prep please
 Monitor FHT and VS q4 hrs
 Refer accordingly

Alternative for Cefuroxime:


 Penicillin G Na 5M U IVT q6 hrs ( ) ANST
 Ampicillin 2g IVT now then 1g IVT q6hr ( ) ANST
Threatened Abortion (Non-septic)

 Please admit patient to ward


 Secure consent
 Low residue diet
 Start IVF w/ D5LR 1L to run 300cc as moderate fast drip
then regulate at 30gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 IF ≤2 weeks
 TVS UTZ
 MEDS:
 Isoxsuprine drip (SD but with no loading of mainline):
D5W 500cc + Isoxsuprine 4amps to run at
20ugtts/mins & increase titration 5ugtts/min q20mins
to a max of 60ugtts/min if there are ongoing uterine
activity or evidence of further cervical dilation; OR
 MgS04 drip (SD but with no loading of mainline):
D5W 1L + MgSO4 10mg to run at 20gtts/min
 CBR without BRP
 Monitor FHT and VS q4 hrs
 Refer accordingly
Imminent / Inevitable Abortion
Imminent Abortion – (+) BOW, open cervix
Inevitable Abortion – (-) BOW, open cervix

 Please admit patient to ward


 Secure consent
 NPO temporarily
 Start IVF w/ D5LR 1L (if inevitable, + oxytocin 10 IU) to
run at 20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 IF ≤2 weeks
 TVS UTZ
 MEDS:
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 Refer to ROD if with passage of abortus or meaty tissue
 For completion curettage once with passage of
products of conception
 Monitor VS q4 hrs, record please
 WOF profuse bleeding or passage of products of
conception
 Perineal prep please
 Refer accordingly
Incomplete Abortion (Septic)
 Please admit patient to ward
 Secure consent
 NPO temporarily
 Start IVF w/ D5LR 1L + oxytocin 10 IU to run at
20gtts/min
 LABS:
 CBC plt, Blood typing
 UA; HBsAg
 CXR PA upright
 Blood & urine GS/CS
 Gram stain of vaginal discharge
 MEDS:
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 Metronidazole 500 mg IVT now then q8 hr
 Paracetamol 300mg IVT q4hrs PRN for fever >37.8
 TT 0.5mL IM
 ATS 3000 IU IM ( ) ANST
 For completion curettage on call
 Secure consent for completion curettage
 Inform DR
 Monitor VS q1 hrs, record please
 Perineal prep please
 Refer accordingly

Alternative for Cefuroxime:


 Penicillin G Na 5M U IVT q6 hrs ( ) ANST
 Ampicillin 2g IVT now then 1g IVT q6hr ( ) ANST
Incomplete Abortion (Non-septic)

 Please admit patient to ward


 Secure consent
 NPO temporarily
 Start IVF w/ D5LR 1L + oxytocin 10 IU to run at
20gtts/min
 LABS:
 CBC plt, Blood typing
 UA
 HBsAg
 MEDS:
 Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
 For completion curettage on call
 Secure consent for completion curettage
 Inform DR
 Monitor VS q4 hrs, record please
 Perineal prep please
 Refer accordingly
Bowel Prep
3-day Bowel Prep
 Day 1
 Low residue diet
 Metronidazole 500mg BID x 3 days
 Bisacodyl 10mg tab TID x 3 days
 Day 2
 Soft diet
 Day 3
 Clear liquids then NPO post-midnight
 Bisacodyl 2 supp at bedtime
 Fleet enema at 5 am
 NO vaginal douche at the ward

1-day Bowel Prep


 Clear fluids then NPO post-midnight
 Metronidazole 500mg BID
 Bisacodyl 2 supp at bedtime
 Fleet enema at 5 am
 NO vaginal douche at the ward
INTERNAL MEDICINE
NOTES
Doctors’ Guide
Infectious
Doctors’ Guide
Upper Respiratory Tract Infection
Symptoms
 Cough, colds
 3 to 5 days duration
Signs
 Nasal discharge (clear or yellowish)
 Clear breath sounds
 No signs of sepsis
 Hemodynamically stable

No labs necessary

Most URTI (even bacterial) resolve without antibiotic


therapy

Antibiotics only for


 Moderate symptoms that are not improving after 10
days
 Symptoms worsen after five to seven days
 Severe symptoms

 Medications
 Amoxicillin 500 mg TID
 Co-amoxiclav 625 mg BID (preferred if failed on
Amoxicillin or if with severe symptoms)
 Azithromycin 250 mg OD x 5 days or 500 mg OD x 3
days or 1 g OD x 1 dose
 Advice
 Increased oral fluid intake (at least 2 L/day)

 Watch out for


 Persistence
 Fever should lyse within 24-48 hours
 Post-infectious cough occurs in 40% of patients
 Recurrence
 Consider allergic rhinitis – may refer to an
allergologist
 Seasonal pattern
 History of asthma or atopy
 Relation to exposure to allergens/certain settings
(bedroom, work)
 If also with weight loss, obstructive ssx, refer to ORL
 Allergic Rhinitis
 If with weekly symptoms, and bothers
sleep/work, must start Fluticasone furoate 2 puffs
per nostril 2x a day for 4-6 weeks
 Exacerbations: Loratadine 10 mg at night
 Itching/Atopy: Cetirizine 10 mg OD
 Discharge: Oxymetazoline spray (may use only
up to 3 days)
 Cough: Dextropmethophan + Phenylephrine
Community-acquired Pneumonia
Symptoms
 Cough with/without sputum production
 Fever
 Generalized weakness, anorexia
Signs
 Crackles
 Decreased breath sounds
 Increased fremiti – consolidation/mass
 Decreased fremiti – pleural effusion
 Wheezing

 Initial Diagnostics
 Chest X-ray
 CBC with platelet count
CAP – Low Risk
 Subsequent Diagnostics
 Sputum GS/CS optional
 Antibiotics
 Previously healthy
 Amoxicillin 1 g TID
 Azithromycin 500 mg OD OR Clarithromycin 500
mg BID
 Stable co-morbid condition (cover enteric G- bacilli)
 Co-amoxiclav 1 g BID
 Sultamicillin 750 mg BID
 Cefuroxime 500 mg BID
 +/- Azithromycin 500 mg OD OR Clarithromycin 500
mg BID

CAP – Moderate Risk


 Subsequent Diagnostics
 Blood CS
 Sputum GS/CS
 Antibiotics
 Ampicillin-Sulbactam 1.5 g IV q6hrs
 Cefuroxime 1.5 g IV q8hrs
 Ceftriaxone 2 g IV OD
 PLUS
 Azithromycin 500 mg OD PO
 Clarithromycin 500 mg BID PO
 Levofloxacin 500 mg OD PO
 Moxifloxacin 400 mg OD PO
 If aspiration is suspected
 Add Clindamycin 600 mg IV q8hr to regimens
under Moderate risk
 Except for:
 Ampicillin-Sulbactam 3 g IV q6hr
 Moxifloxacin 400 mg OD PO
CAP – High Risk
 Subsequent Diagnostics
 Blood CS
 Sputum GS/CS
 Urine antigen for L. pneumophila
 Direct fluorescent Ab test for L. pneumophila
 ABG
 Antibiotics
 no risk for Pseudomonas aeruginosa
 Same as moderate risk
 Ertapenem 1 g IV OD
 with risk for Pseudomonas aeruginosa
 Piptazo 4.5 g IV q6hrs
 Cefepime 2 g IV q8-12hrs
 Meropenem 1 g IV q8hrs
 PLUS
 Azithromycin 500 mg IV OD + Gentamycin 3
mg/kg OD OR Amikacin 15mg/kg OD OR
 Levofloxacin 750 mg IV OD or Ciprofloxacin 400
mg IV q8-12hrs
 If MRSA suspected, add any of the following:
 Vancomycin 15 mg/kg IV q8-12hrs
 Linezolid 600 mg IV q12hrs
 Clindamycin 600 mg IV q8hrs

Suspect Pseudomonas aeruginosa, IF


 Antibiotic use (at least 1 week in the past month)
 Malnutrition
 Steroid use (Prednisone 2.5 mg in the past week)

 Watch out for


 Pleural effusion, Lung abscess
 Do thoracentesis
 Refer to TCVS for CTT if warranted
 Hemodynamic instability/Progressing sepsis
 Refer to Pulmo, IDS
 Hospital-acquired pneumonia
 Proper precautions in intubated patients
 Exacerbation of co-morbid diseases

 Resolution
 For low-risk
 Follow-up after 3 to 5 days
 For moderate-/high-risk
 Step down when clinically improving
 Some infections (e.g. ESBL organisms) require a full
course via the IV route
 Chest X-ray findings
 May take up to 6 months to completely resolve
 Vaccination (including those with co-morbid)
 Pneumococcal: one time, then q5years
 Influenza: annually
Urinary Tract Infection
Symptoms of Urethritis
 Acute dysuria, hematuria
 Frequency
 Pyuria
 Recent sexual partner change
Signs of Urethritis
 Grossly purulent discharge expressed in genital tract

Symptoms of Cystitis
 Dysuria, Urgency
 Suprapubic pain
 Hematuria, foul-smelling urine, turbid urine
Signs of Cystitis
 Suprapubic tenderness
 Fever

Symptoms of Acute Pyelonephritis


 Rapid development
 Fever, shaking chills
 Nausea, vomiting, abdominal pain
 Diarrhea
 Diabetes, immunosuppression
Signs of Acute pyelonephritis
 Costoverterbal angle tenderness at side of involved
kidney
 Fever, signs of sepsis

Symptoms of catheter-related UTI


 Minimal symptoms
 Usually no fever
Signs of catheter-related UTI
 Turbid/foul-smelling urine
 Purulent discharge
 Suprapubic tenderness
Does the patient have complicating risk factors?
 Anatomic abnormality
 Functional abnormality
 Recent UTI or Tract instrumentation (past 2 weeks)
 Renal disease/transplant
 Antibiotic use (Past 2 weeks)
 Immunosuppression
 DM
 Catheter, indwelling/intermittent
 Hospital-acquired
 Symptoms for > 7 days

Uncomplicated Cystitis
 Medications (do 7 day regimen in males)
 Cotrimoxazole 800/160 PO BID x 3 days
 Ciprofloxacin 250 mg PO BID x 3 days
 Ofloxacin 200 mg PO BID x 3 days
 Norfloxacin 400 mg PO BID x 3 days
 Nitrofurantoin 100 mg QID x 7 days
 Cefuroxime 125-250 mg PO BID x 3-7 days
 Increase OFI
 In MALES
 U/A or urine cultures in males

If unresolved after 7 days, consider as COMPLICATED

Acute Uncomplicated Pyelonephritis


 Diagnostics
 Urinalysis (expect increased WBC; bacteriuria not the
defining parameter; WBC cast is pathognomonic)
 Urine GS/CS

Outpatient treatment:
 No signs and symptoms of sepsis
 Non-pregnant
 Likely to comply with treatment
 Able to tolerate oral medications
 Follow-up after 3-5 days

 Empiric regimen should be started after culture is taken


 Oral antibiotics
 Ofloxacin 400 mg BID x 14 days
 Ciprofloxacin 500 mg BID x 7-10 days
 Levofloxacin 250 mg OD x 7-10 days
 Cefixime 400 mg OD x 14 days
 Cefuroxime 500 mg BID x 14 days
 IF GS+
 Co-amoxiclav 625 mg TID x 14 days
 IV antibiotics (given until patient is afebrile)
 Ceftriaxone 1-2 g IV OD
 Ciprofloxacin 200-400 mg IV q12hrs
 Levofloxacin 250-500 mg IV OD
 IF GS+
 Ampicillin-Sulbactam 1.5 g IV q6hrs
 Piperacillin-Tazobactam 2.25-4.5 g IV q6-8hrs

 Watch out for


 Fever after 72 hours of treatment, or recurrence of
symptoms
 Imaging studies (KUB-UTZ , KUB-IVP if Creatinine
clearance acceptable)
 Repeat urine culture
 If without urologic abnormality, treatment duration
is 2 weeks based on culture
 If same organism between initial and repeat
culture, treatment duration is 4-6 weeks
Asymptomatic bacteriuria
 Defined as ≥ 100,000 cfu in 2 consecutive midstream
urine specimens or 1 catheterized specimen
 Should screen for, and treat in
 Patients who will undergo GU manipulation or
instrumentation
 Post-renal transplant patients up to first 6 months
 DM with poor glycemic control, autonomic
neuropathy or azotemia
 All pregnant women
 Same antibiotics as acute uncomplicated cystitis

Recurrent Urinary Tract Infection


 More 2x a year, with no urinary tract abnormalities
 May give prophylaxis (if symptoms are
unacceptable)
 Post-coital (immediately after intercourse)
 Daily for 6 to 12 months
 Nitrofurantoin 100 mg at bedtime
 Cotrimoxazole 200/40 mg at bedtime
 Ciprofloxacin 125 mg at bedtime
 Norfloxacin 200 mg at bedtime
 Cefalexin 125 mg at bedtime
 Same antibiotics as acute uncomplicated cystitis, or
may also take 2 double strength Cotrimoxazole
single dose as soon as symptoms first appear
Complicated Urinary Tract Infection
 Outpatient
 No signs of sepsis
 Without marked debilitation
 Ability to comply with treatment
 Ability to maintain oral hydration/take oral
medications

 Diagnostics
 Urine GS/CS
 Antibiotics
 Oral antibiotics
 Ciprofloxacin 250 – 500 mg BID x 14 days
 Norfloxacin 400 mg BID x 14 days
 Ofloxacin 200 mg BID x 14 days
 Levofloxacin 250 – 500 mg OD x 10-14 days
 Parenteral antibiotics
 Ampicillin-sulbactam 1.5 – 3 g IV q6
 Ceftazidime 1-2 g IV q8hrs
 Ceftriaxone 1-2 g IV OD
 Imipenem-cilastin 250-500 mg IV q6-8hrs
 Piperacillin-Tazobactam 2.25 g IV q6hrs
 Ciprofloxacin 200-400 mg IV q12hrs
 Ofloxacin 200-400 mg IV q12hrs
 Levofloxacin 500 mg IV OD

 At least 7 to 14 days of therapy


 Urine culture should be repeated 1 to 2 weeks after
completion of medications
 If persistent, refer to urology/nephrology
 If no response, may do
 Plain KUB x-ray
 KUB-UTZ
 Helical CT scan
Catheter-associated UTI
 If asymptomatic, no need to treat, except if
 With bacterial agents with high-incidence
bacteremia
 With neutropenia
 Pregnant
 Will undergo urologic procedures/post-renal
transplant
 Indwelling catheter should be removed
 Long-term indwelling catheters should be replaced
before treatment

Candiduria
 May treat if
 Symptomatic
 Critically ill
 Neutropenic
 Will undergo urologic procedures/post-renal
transplant
 Control diabetes (if present)
 Remove catheter, other urinary tract instruments (if
present)
 Cystitis
 Fluconazole 400 mg LD then 200 mg OD x 7-14
days
 Pyelonephritis
 Surgical drainage
 Fluconazole 6 mg/kg/day OR Amphotericin B IV 0.6
mg/kg/day for 2 to 6 weeks
Dengue Fever
Warning Signs
 Abdominal pain or tenderness
 Persistent vomiting
 Clinical fluid accumulation
 Mucosal bleed
 Lethargy, restlessness
 Liver enlargement > 2 cm
 Increase in hematocrit WITH decrease in platelet
count

Severe Dengue
 Severe plasma leakage leading to
 Shock (Dengue Shock Syndrome)
 Fluid accumulation with respiratory distress
 Severe bleeding (esp. with use of ASA, Ibuprofen or
corticosteroids)
 Severe organ involvement
 Liver: AST or ALT > 1000
 CNS: Impaired consciousness
 Heart and other organs

 Initial Diagnostics
 CBC with PC
 Leukopenia
 Thrombocytopenia
 Hemoconcentration
 Dengue IgM – esp. if with unusual/atypical
manifestations
 Dengue NS1
 Crea, Na, K, AST, ALT
 Elevated AST more than ALT
 Liver function: Protime, TB, DB, IB, albumin
Dengue Fever - Group A
Who:
 Can tolerate oral fluids
 UO every 6 hours
 No warning signs

 May be sent Home


 ORS, fruit juice
 Paracetamol for high fever, TSB
 Possible follow-up if with complications
Dengue Fever - Group B
Who:
 Warning signs
 Co-existing conditions (e.g. pregnancy, DM, extreme
age)

 Admit
 Hct before fluids
 Isotonic solution (pNSS, Ringer’s lactate)
 5-7 mL/kg/hr for 1 to 2 hours
 3-5 mL/kg/hr for 2 to 4 hours
 For obese/overweight: use ideal body weight
 May give oral fluids if tolerated
 If Hct remains the same/Clinical status stable
 2-3 mL/kg/hr for another 2 to 4 hours
 If Hct rises/Clinical status worsens
 5-10 mL/kg/hr for 1 to 2 hours
 Try to maintain UO 0.5 mL/kg/hr
 Fluids usually needed for only 24-48 hours
 Monitoring
 VS q1-4, UO q4-6 then q6-12 if stable
 Hematocrit after fluid then q6-12
 Transfer to tertiary care if:
 Early presentation of shock (2nd or 3rd day)
 Severe plasma leakage or shock
 Undetectable pulse or BP
 Severe bleeding
 Fluid overload
 Organ impairment
Dengue Fever - Group C
Who:
 Severe plasma leakage
 Severe hemorrhage
 Severe organ impairment

 Monitoring
 VS q15-30 until out of shock then q1-2
 Cardiac monitor
 Pulse oximetry
 Arterial line if possible
 BP
 Blood extraction
 Bleeding
 Avoid intramuscular injections
 If mucosal, treat as minor bleeding – resuscitation as
specified
 Major Bleeding
 Prolonged/refractory shock
 Renal/Liver failure or persistent metabolic acidosis
 NSAID intake
 Anticoagulant therapy
 Preexisting PUD
 Any form of trauma, including intramuscular
injections
 Don’t wait for drop: Hct <0.3 in sepsis is NOT
applicable
 5-10 mL/kg pRBC or 10-20 mL/kg of Whole Blood
 Platelet concentrates or FFP DO NOT HELP!
 May do only if pRBC and FWB does not work
 Exacerbates fluid overload
 NGT insertion must be done fully lubricated and with
care
Resolution
 1 week course
 Discharge if
 Increasing trend of platelet count
 No bleeding
 No hemodynamic instability
 Advice regarding mosquito control
 Ablation of mosquito breeding grounds
 Mosquito nets rather than mosquito repellents
Typhoid Fever

Symptoms
 High grade fever in past 1 to 2 weeks
 Abdominal pain (not always present)
 Headache, chills, cough, myalgia/arthalgia,
diarrhea or constipation
Signs
 Relative bradycardia at the peak of fever
 Hepatosplenomegaly, abdominal tenderness
 Rose spots: faint, salmon-colored blanching rash
usually located on the trunk

 Diagnostics
 CBC with PC (leukocytosis, sometimes leukopenia,
neutropenia)
 Crea, Na, K, AST, ALT (slightly elevated LFTs)
 Blood CS (sensitivity 90% in first week)
 Bone marrow CS (even up to 5 days of therapy)
 Duodenal string test/culture
 Stool CS (positive in 3rd week if untreated)
 Admit if…
 Vomiting, diarrhea, abdominal distension
 Empirical treatment
 Ceftriaxone 1-2 g IV OD x 7-14 days
 Cefixime 400 mg PO BID x 7-14 days
 Azithromycin 1g PO OD x 5 days
 Multidrug resistant
 Ciprofloxacin 500 mg PO BID x 5-7 days
 Ciprofloxacin 400 mg IV q12 x 5-7 days
 Ceftriaxone 2-3 g IV OD x 7-14 days
 Azithromycin 1g PO OD x 5 days
 Critically ill (shock, obtundation)
 Add Dexamethasone 3 mg IV then 1 mg/kg q6 x 8
doses
 Admit to ICU
 Refer to IDS
 Repeat cultures if none were positive

 Watch out for


 Perforation/Obstruction
 Due to invasion of Peyer’s patches
 Refer to Surgery
 Continued fever
 Lack of susceptibility
 Consider another etiology
 Refer to an Infectious Disease specialist

Resolution
 Defervescence in 1 week
 Return to normal values also in 1 week
Leptospirosis
Symptoms
 Wading in floodwater/exposure to mud
 Influenza-like illness: chills, headache, nausea,
vomiting, muscle pain (calves, back or abdomen)
 Fever, conjunctival suffusion/hemorrhage
 Hemoptysis
 Decreased urine output, tea-colored urine
 Overt jaundice
 Diarrhea
 Course progresses within 1 week, rarely 2 weeks

Signs
 Fever
 Conjunctival suffusion
 Jaundice and icterus
 Calf tenderness
 Decreased sensorium

 Initial Diagnostics
 Lepto MAT/Dri-Dot
 BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for acute
renal failure, electrolyte losses)
 Urinalysis (concentrated urine vs renal failure; picture
of UTI may confuse you)
 CBC with PC (anemia, leukocytosis)
 Chest X-ray (check for pulmonary hemorrhage)
 Stool CS (for patients with diarrhea)
 Urine culture (positive at 2nd to 4th week, and for
several months after)
 Mild Leptospirosis
 Doxycycline 100 mg PO BID
 Ampicillin 500-750 mg PO QID
 Amoxicillin 500 mg PO QID
 Moderate/Severe Leptospirosis
 Penicillin G 1.5 M u IV QID
 Ampicillin 1 g IV QID
 Amoxicillin 1 g IV QID
 Ceftriaxone 1 g IV OD
 Erythromycin 500 mg IV QID
 Hydration
 Based on urine output
 Replace electrolytes lost
 Transfusion
 Based on losses detected by CBC
 Control of hemoptysis
 Hydrocortisone 50 mg IV q6hrs
 Tranexamic Acid 500 mg TID

 Weil’s syndrome
 Heralded by hemoptysis, renal failure, severe liver
dysfunction, or sepsis
 Refer to Infectious Disease specialist
 Refer to Renal service for early dialysis
 Transfer to ICU
 Jarisch-Herxheimer reaction
 Occurs in response to antimicrobial therapy, when
massive spirochete kill releases lipoproteins
 Simulates worsening of disease
 Fever, chills, myalgias, headache
 Tachycardia, tachypnea
 Increased WBC, neutrophils
 Hypotension
 Supportive therapy
 Subsides after 12-24 hours without revision of meds

Resolution
 Jaundice to resolve in 2 to 4 weeks
 May discharge if
 Creatinine clearance is on upward trend
 Urine output at least 0.5 cc/kg/hr
 Electrolytes corrected
 Platelet/hemoglobin corrected
 No ongoing hemoptysis
 Prophylaxis
 Doxycycline 200 mg PO once a week if exposed
Cardiology
Doctors’ Guide
Hypertension: Presentation
Symptoms
 Frequently asymptomatic
 Aching nape/occipital area
 Symptoms of target organ damage
Signs: Try to detect both cause and effect…
 Kidney disease: anemia, oliguria, sallow skin
 Cushing’s syndrome: obesity, striae, moon facies,
etc.
 Hyper/hypothyroidism
 Heart failure
Signs: Taking Blood Pressure
 Aneroid instrument vs mercury based instruments
 Seated quietly for 5 minutes (Quiet, private, with
comfortable room temperature)
 Bladder cuff is at least half of arm circumference
 Deflation is 2 mmHg/s
 Measure both arms, in supine, sitting and standing
positions (detects coarctation, orthostatic changes)
 Measure 1 leg at least once (take ABI)
 Palpate all possible pulses
 Cardiac examination is important
 Auscultate carotid and renal bruits

Classification Systolic Diastolic


Normal < 120 AND < 80
Prehypertension 120 – 139 OR 80 – 89
Stage 1 140 – 159 OR 90 – 99
Stage 2 ≥ 160 OR ≥ 100
 Diagnostics
 Urinalysis (renal cause and complication)
 BUN, Crea, Na, K, Ca, alb (low K is clue for
aldosteronism and pheochromocytoma)
 FBS, Lipid profile (co-morbidities)
 CBC (anemia)
 ECG (LVH, other abnormalities)
 Lifestyle changes (BEADS)
 BMI < 25 kg/m2
 Exercise: Near-daily to daily aerobic activity
 Alcohol avoidance/moderation
 DASH diet: fruits, vegetables, low fat dairy, reduced
saturated and total fat
 Salt-restriction: NaCl < 6 g/d

 First-line agents (JNC 8)* Including those with diabetes


 Thiazide-type diuretic
 Calcium channel blocker (CCB)
 Angiotensin-converting enzyme inhibitor(ACEI)
 Angiotensin receptor blocker (ARB)

 Diuretics
 Examples
 Hydrochlorothiazide 12.5 – 25 mg OD-BID
 Furosemide 40-80 mg BID-TID
 Spironolactone 25-100 mg OD-BID
 Good for heart failure
 Caution in DM, gout, renal failure
 K reducer: furosemide, HCTZ
 K retainer: spironolactone
 Beta blockers
 Examples
 Atenolol 25-100 mg OD
 Metoprolol 25-100 mg OD-BID
 Propranolol 40-160 mg BID (not cardioselective)
 Carvedilol 12.5-50 mg BID (combined alpha and
beta)
 Good for heart failure, angina, MI, tachycardia
 Caution in 2nd or 3rd degree AV block, asthma/COPD
 ACE inhibitors
 Examples
 Captopril 25-200 mg BID-TID
 Enalapril 5-20 mg OD
 Lisinopril 10-40 mg OD
 Ramipril 2.5-20 mg OD-BID
 Good for heart failure, MI, DM
 Caution in renal failure, hyperkalemia, renal artery
stenosis, pregnancy
 May cause cough, angioedema
 Angiotensin receptor blockers
 Examples
 Losartan 25-100 mg OD-BID
 Valsartan 80-320 mg OD
 Candesartan 2-32 mg OD-BID
 Good for heart failure, MI, DM
 Caution in renal failure, hyperkalemia, renal artery
stenosis, pregnancy
 Used as second-line to ACE-inhibitors
 Dihydropyridine CCBs
 Examples
 Amlodipine 5-10 mg OD
 Long-acting Nifedipine 30-60 mg OD
 Good for angina
 Caution in heart failure, 2nd or 3rd degree AV block
 Causes peripheral edema
 Non-Dihydropyridine CCBs
 Examples
 Long-acting Verapamil 120-360 mg OD-BID
 Long-acting Diltiazem 180-420 mg OD
 Good for angina, MI, DM, tachycardia
 Caution in heart failure, 2nd or 3rd degree AV block
 Causes peripheral edema
Direct Vasodilators
 Examples
 ISMN 30-60 mg OD
 ISDN 5-10 mg BID-TID
 Hydralazine 25-100 mg BID-TID
 Nitrates good for angina, MI
 Nitrates cause hypotension, headache (must have
at least 8 hours a day drug free), and has reaction
with sildenafil
 Hydralazine should not be used in severe coronary
artery disease

 BP Targets (JNC 8)
 In the general population aged ≥ 60 years
 Initiate pharmacologic treatment to lower blood
pressure (BP) at systolic blood pressure (SBP) ≥150
mm Hg or diastolic blood pressure (DBP) ≥ 90
mmHg
 Target BP <150/90 mm Hg
 In the general population aged < 60 years, including
those with CKD or diabetes
 Initiate pharmacologic treatment to lower blood
pressure (BP) at systolic blood pressure (SBP) ≥140
mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg
 Target BP <140/90 mm Hg
 Follow-up
 Adjustment
 Diuretics: daily to weekly (electrolyte imbalances)
 Beta-blockers: every 2 weeks
 ACE-inhibitors and ARBs: every 1 – 2 weeks
 CCBs: every 1 – 2 weeks
 Vasodilators: Every 1 – 2 weeks

 Watch out for…


 Secondary Hypertension
 CGN/Nephrotic syndrome/CKD: urinary findings,
edema
 Pheochromocytoma: sweating, palpitations,
headache, early target organ damage
 Primary aldosteronism: resistant to medications, low
K, weakness
 Connective Tissue Disease: pulse discrepancy,
systemic symptoms
 Refer to Renal/Endo/Rheuma

Hypertensive Urgency vs Emergency


 Both require admission
 Emergency: presence of target organ damage
 Reduce blood pressure by 25% over minutes to 2
hours
 Parenteral agents
 Urgency: No target organ damage
 Reduce blood pressure over hours
 Oral agents

 Medications
 Nitroprusside: 0.3 ug/kg/min, maximum at 10
ug/kg/min; discontinue if no response after 10
minutes
 Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at
3 to 5 minute intervals
 10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in
100 mL
 Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15
minute intervals, maximum at 15 mg/h
 2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in
100 mL
Angina and Acute Coronary Syndromes
Symptoms
 Heaviness, pressure, squeezing, localized
retrosternally
 Crescendo vs decrescendo
 Radiates anywhere between the mandible and
umbilicus
 Related to exertion
Signs
 High/low blood pressure, tachy/bradycardia
 Heart failure

 Complete bed rest


 Oxygenation
 Target O2 saturation > 90%
 Nasal cannula vs face mask vs intubation
 Cardiac monitor
 Vital signs
 Ask about sildenafil use in past 24 hours
 Viagra, cialis, ambigra, adonix, erefil, neo-up
 Give nitrates
 Nitroglycerin 0.3-0.6 mg, or via buccal spray
 ISDN 5 mg sublingual
 3 doses 5 minutes apart
 If persistent, start Nitroglycerin drip
 10 mg in 100 mL, start at 5 ug, and increased by 5-
10 ug/min
 Titrated every 3 to 5 minutes until symptoms are
relieved or systolic arterial pressure falls to < 100
mmHg
 Good for pulmonary congestion
 Caution in: inferior wall/right-sided infarcts
(hypotension)
 Initial Diagnostics
 12-lead ECG (within 10 minutes)
 2D-echocardiogram
 BUN, Crea, Na, K, Ca, alb, Mg, AST
 Cardiac enzymes: Trop I/T > CKMB > CKtotal
 Urinalysis
 Chest X-ray
 PT/PTT
 Optional: Nuclear perfusion scan, cardiac MRI,
cardiac PET
UAHR/NSTEMI/STEMI
 Loading Dose
 Aspirin 80 mg/tab 4 tabs chewed and swallowed
 Clopidogrel 75 mg/tab 4 tabs chewed and
swallowed
 Metoprolol 5 mg IV q5 up to 15 mg (3 doses), then
followed in 1-2 hours by 25-50 mg PO q6
 Morphine 2-5 mg IV repeated q5-30 minutes
 Captopril 25 mg/tab ½ to 1 tab q8
 Heparinization (unfractionated heparin or low
molecular weight heparin)
 Decide whether to do PCI or not
 Referral center should be no more than 30 mins
away
 Door-to-balloon time should be at most 90 mins
 Golden period: not more than 6h, may give 12h
after
 Refer to CVS for thrombolysis
 Take informed consent
 Streptokinase 1.5 M u in pNSS to make 100 cc to
consume over 1 hour
 Pre-medication with Diphenhydramine 1 amp IV
 Can have hemorrhage, allergic reactions
Absolute contraindications to thrombolysis
 Cerebrovascular hemorrhage at any time
 Known structural cerebral vascular lesion (e.g. AVM)
 Non-hemorrhagic stroke/event in the past year
 Ischemic stroke within 3 months, except if within 3hr
 Hypertension (SBP > 180, DBP > 110)
 Suspicion of aortic dissection
 Must do Chest/abdominal CT stat if suspected
 Active internal bleeding except menses
 Any known malignant neoplasm
 Significant closed head/facial trauma in past 3
months
Aspirin and Clopidogrel
 Part of antithrombotic therapy
 Maintenance
 Aspirin 80 mg/tab 1 tab OD (with a meal)
 Clopidogrel 75 mg/tab 1 tab OD
 WOF GI bleed, allergy to aspirin
Beta blockers
 Part of anti-ischemic therapy
 Maintenance
 Metoprolol 50 mg BID
 Target: HR 50-60 bpm
 Caution in hypotension, asthma, COPD. Severe
pulmonary edema
Calcium channel blockers
 Part of anti-ischemic therapy
 Used in patients with contraindication to beta
blockers
 Maintenance
 Long-acting Verapamil 120-360 mg OD-BID
 Long-acting Diltiazem 180-420 mg OD
 Target: HR 50-60 bpm, no chest pain
 Avoid rapid-release CCB (e.g. nifedipine)
 Caution in pulmonary edema, severe LV
dysfunction, hypotension, bradycardia, heart-block
Morphine
 Part of anti-ischemic therapy
 Maintenance
 None – PRN use only
 Target: no chest pain
 Caution in inferior wall/right ventricular infarction,
hypotension, respiratory depression, confusion,
obtundation
ACE-inhibitors
 Part of long-term cardiac therapy
 Maintenance
 Captopril 25 mg 1 tab q8
 Enalapril 5-20 mg OD
 Gradual increase as patient stabilizes
 Good for LV dysfunction, anterior wall MI
 Caution in hypotension, renal failure, hyperkalemia
Statins
 Part of long-term cardiac therapy
 Plaque stabilization
 Maintenance (@HS doses)
 Atorvastatin 10 mg, max 80 mg
 Rosuvastatin 10 mg, max 40 mg
 Simvastatin 20 mg, max 80 mg
 Gradual increase over a period of 2 months
 Good for dyslipidemia, MI
 Caution in liver disease, rhabdomyolysis
Heparin
 Part of anti-thrombotic therapy
 Types
 UFH 60 U LD, then 12U/kg/h target PTT 1.5-2.0x
normal
 Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 (OD
if creatinine clearance < 30 mL/min)
 Fondaparinux 2.5 mg SC OD
 If patient is unstable, has poor hemodynamic status,
or has risk of bleeding, age > 75 y/o, UFH is preferred
 PTT measurements should be done q6
 Duration is 2 to 5 days
Targets
 Activity (SUPERVISED)
 First 12 hours: Bed rest
 12-24 hours: Dangling legs/sitting in a chair
 2nd - 3rd day: Ambulation in room, go to shower
 3rd day and beyond: 185 m (600 feet) at least 3x a
day
 Sexual activity: 2-4 weeks after event
 Work: 1 month after event
 Diet
 First 4-12 hours: NPO
 If stable: Complex carbohydrates (50-55%), Fat <
30%, total cholesterol < 200 mg/d, fiber rich
 Bowel care
 Stool softeners
 Bedside commode rather than bedpan
 Laxative
 Sedation
 Quiet, reassuring environment
 Diazepam 5 mg TID-QID
 Tight glycemic control
 Insulin drip preferred in acute setting
 Pre-prandial: 90-130 mg/dL (critical care: < 110)
 Post-prandial: < 180 mg/dL (critical care: < 180)
 Long-term: HbA1c < 7%
 Electrolyte
 Mg - 1.0 mmol/L
 K - 4.0-4.5 mmol/L
 Ca - 2.12-2.52
 Discontinue O2
 May discontinue starting 6 hours after admission, if
O2 saturation > 90%
 Watch out for...
 Arrhythmia
 Defibrillate with maximum dose available up to 3x
 Amiodarone 150 mg in 50 to 100 cc pNSS over 10
minutes, then drip 360 mg in D5W x 6 hours
 Refer to CVS
 Mechanical complications
 Wall rupture
 New-onset mitral regurgitation
 Pericarditis
 Refer to CVS/TCVS

Resolution
 Follow-up after 2 weeks
 For treadmill exercise test (if appropriate)
 Titration of medications
 Strengthen previous advice

Chronic Stable Angina


Symptoms
 Same as acute angina
 Symptoms > 2 weeks
 No worsening, crescendo pattern over hours/weeks
 No increase in frequency
Signs
 Hemodynamically stable
 Complete cardiovascular PE should be done

 Diagnostics
 12-L ECG
 Treadmill exercise test
 2D-echo
 Crea, Na, K, Mg. Ca, alb
 Lipid profile, FBS
 Chest X-ray
 Medications
 Anti-platelet
 Aspirin 80 mg OD
 Clopidogrel 75 mg OD if ASA-intolerant
 Beta blocker
 Atenolol 25-100 mg OD
 Metoprolol 50-100 mg OD-BID
 Carvedilol 6.25-50 mg BID
 ACE inhibitor
 Captopril 25-200 mg BID-TID
 Enalapril 5-20 mg OD
 Lisinopril 10-40 mg OD
 Ramipril 2.5-20 mg OD-BID
 Statin
 Atorvastatin 10 mg, max 80 mg @HS
 Rosuvastatin 10 mg, max 40 mg @HS
 Simvastatin 20 mg, max 80 mg @HS

If with high-risk features, or positive stress test, advice


coronary angiography with intervention
 Useless to do CA without intervention
 PCI vs CABG depends on clinical picture
 Refer to CVS in an institution with PCI/CABG
capability
Pulmonology
Doctors’ Guide
Asthma
Symptoms
 Trigger
 Allergen
 URTI/Pneumonia
 Beta blockers. Aspirin
 Exercise. Cold air, hyperventilation, laughter
 Occupational asthma (Mondays)
 Stress
 Dyspnea, shortness of breath, chest tightness
 Night exacerbations
 Cough
 Younger age group
Signs
 Tachypnea
 Tachycardia, hypertension
 Wheezing
 Absence of wheezing = severe
 Clubbing = uncontrolled

 Diagnostics
 ABG (hypercarbia, hypoxemia, alkalosis)
 Chest X-ray (rule out infection, other differentials)
 12-L ECG (rule out cardiac causes of dyspnea
 CBC with PC (infection)
 Oxygenation
 O2 support
 Intubation if in impending/frank respiratory failure
 Short acting inhaled beta-agonists
 Salbutamol nebulization q5-15
 WOF tremors, palpitations
 Inhaled anti-cholinergics
 Ipatropium bromide nebulization q5-15
 WOF Dry mouth, decreased sputum production/dry
cough
 Glucocorticoids
 Hydrocortisone 50 mg IV q6 or 100 mg IV q8
 Budesonide nebule q8
 WOF Hoarseness, dysphonia, oral candidiasis,
systemic effects
 Aminophylline drip
 Mix as 1mg/mL
 LD 6 mg/kg over 20-30 minutes
 Maintenance at 1 mg/kg/hr (use lower dose in
elderly, or in nonsmokers)
 Hook to cardiac monitor
 WOF flushing, diarrhea, nausea, vomiting,
arrhythmias
 If with status asthmaticus, admit to ICU
 Refer to anesthesia if previous measures don’t work
 Propofol, Halothane
 Treat infection
 Most common is still viral URTI (supportive therapy)
 See CAP guidelines if with pneumonia
 Check if drug is the trigger
 Discharge
 No wheezing and tolerates room air
 No IV glucocorticoids
 Infection is treated
Resolution
 Home medications:
 Oral steroid with tapering schedule
 Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing
 Combination inhaled corticosteroid with long-acting
inhaled beta-agonist
 Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2
puffs BID
 Fluticasone + Salmeterol 500/50 or 250/50 or 100/50
1-2 puffs BID
 Gargle after use
 Rescue doses of short acting inhaled beta-agonists
 Salbutamol neb PRN
Outpatient Care
OCS
LABA LABA LABA
ICS low ICS low ICS low ICS low
dose dose dose dose
SABA SABA SABA SABA SABA
Mild Mild Moderate Severe Very severe
intermittent persistent persistent persistent persistent
Symptoms ≤ 2/week 3-6/week Daily Daily Unremitting
3-
Night ≤ 2/month ≥ 5/moth Frequently Nightly
4/month

 Smoking cessation
 Influenza vaccination annually
 Pneumococcal vaccination once then q5 years
Chronic Obstructive Pulmonary Disease
Symptoms
 Cough, sputum production, exertional dyspnea
 Smoking
 Decreased functional capacity
 Chronic symptoms
 Older age group
Signs
 Wheezing
 Clubbing, cyanosis
 Barrel-chest

 Diagnostics
 ABG (hypercarbia, hypoxemia)
 Chest X-ray (infection, chronic changes –
hyperinflation, fibrosis, cause of COPD)
 CBC with PC (infection)
 12-L ECG (consider cardiac etiology)
 Oxygenation
 O2 support
 Intubation if in impending/frank respiratory failure
 Short acting inhaled beta-agonists AND inhaled anti-
cholinergics
 Salbutamol nebulization q5-15
 Ipatropium bromide nebulization q5-15
 Methylxanthine
 Theophylline 10-15 mg/kg in 2 divided doses
 Comes in 100, 200, 300, 400, 450 mg
 Glucocorticoids
 Hydrocortisone 50 mg IV q6 or 100 mg IV q8
 Budesonide nebule q8
 Shift to Prednisolone/Prednisone 30-40 mg to
complete 2 weeks
 Antibiotics
 Bronchiectasis with increased sputum production
 2 weeks of antibiotics directed against path
 WOF
 Cor Pulmonale
 Right heart enlargement on X-ray, ECG
 Prominent neck veins and peripheral edema
 Careful diuresis
 Furosemide 20-40 mg BID
 Spironolactone 25-100 mg OD-BID

Resolution
 Complete smoking cessation
 Pulmonary Rehabilitation (Refer to Rehab)
 Lung volume reduction surgery in severe emphysema
 Oxygen therapy
 Resting O2 sat < 88%
 O2 sat < 90% if with pulmo HTN, cor pulmonale
 Influenza vaccination annually
 Pneumococcal vaccine once then q5 years
Endocrinology
Doctors’ Guide
Diabetes Mellitus
Symptoms
 Weight loss, unexplained
 Polyuria, polydipsia
 Frothy urine
 Decreased vision
 Poorly healing wounds, frequent infections
 Paresthesias, numbness
 Stroke, MI previously
 DKA: abdominal pain, nausea, vomiting, young
 HHS: poor appetite, increased sleeping time, elderly
Signs
 Decreased sensation
 Non-healing wound
 Skin atrophy, Muscle atrophy
 Diabetic dermopathy (necrobiosis lipiodica
diabeticorum)
 Renal failure
 Retinopathy
 DKA: ketone breath, normal abdomen, tachycardic,
tachypneic
 HHS: obtundation, dehydration
DM Emergency
 Diagnostics
 CBC with PC (infection, anemia)
 RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P (azotemia,
low albumin, electrolyte imbalances, anion gap)
 Plasma ketones if available
 ABG
 Chest X-ray (and X-ray of involved extremity if with
non-healing wound)
 Urinalysis with ketones
 12-L ECG
 HBA1c (instead of FBS)
 CBG
 Computations
 Osmolality
 2(Na + K) + BUN + RBS (in mmol/L)
 Normal is 276-290 mmol/L
 Anion gap
 Na – (Cl + HCO3)
Normal is 10-12 mmol/L
DKA
HHS
Mild Mod Severe
Plasma glucose
>250 >250 >250 >600
(mg/dL)
7.25 – 7.00 -
Arterial pH <7.00 >7.30
7.30 <7.24
Serum HCO3 15 – 18 10 - <15 <10 >15
Urine ketones Positive Positive Positive Small
Serum ketones Positive Positive Positive Small
Effective serum
osmolality Var Var Var >320
(mOsm/kg)
Anion gap >10 >12 >12 <12
Alert / Stupor Stupor
Sensorium Alert
drowsy /coma /Coma
 ICU admission
 If unstable
 pH < 7.00
 Decreased sensorium
 Refer to Endo
 Replace fluids
 2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h)
 0.45% NSS at 150-300 mL/h
 D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250 mg/dL
 WOF congestion, hyperchloremia
 HHS: if Na > 150, use 0.45% NSS at the onset
 Insulin
 Start only if K > 3.3
 0.1-0.15 u/kg IV bolus
 0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL
 20 or 100 units regular insulin in pNSS to make 100
cc in soluset dripped via infusion pump (1cc = 1u if
100 u used)
 Decrease insulin until 0.05-0.1 u/kg/h
 As soon as patient is awake and tolerates feeding,
may start patient on diet
 Overlap insulin with subcutaneous insulin
 Calculate insulin requirements from insulin drip
used in past 24 hours
 Assess precipitant
 Noncompliance/missed insulin dose
 Infection (UTI, pneumonia)
 Myocardial infarction
 Drugs
 CBG q1-2 hours
 Electrolytes and ABG q4 for first 24 hours
 NVS, I/O q1
 Correct potassium
 K < 5.5: 10 mEq/h
 K < 3.5: 40-80 mEq/h
 Correct acidosis only if pH < 7.0 after initial hydration
 pH 6.9-7.0: 50 mEq NaHCO3 + 10 mEq KCl in 200 mL
sterile water x 1h
 pH < 6.9: 100 mEq NaHCO3 + 20 mEq KCl in 400 mL
sterile water x 2h
 Repeat ABG 2 hours after
 Repeat dose q2 hours until pH > 7.0
 Correct magnesium
 Target 0.8 to 1 mmol/L
 Each gram of Mg will increase Mg by 0.1 mmol/L
 3g MgSO4 in D5W 250 cc x 12h = 0.3 additional Mg

Watch out for…


 Nephropathy
 Refer to Renal if with decreasing urine output, low
creatinine clearance, for possible HD
 Ophthalmopathy/Retinopathy
 Refer to Ophtha
 Diabetic foot ulcer
 Refer to Ortho/TCVS
 Deterioration in sugar control
 See previous orders
 Refer to Endo
 Acute coronary event
Sliding Scale Insulin Protocol

CBG HRI Monitoring


0 – 80 0 Refer
1amp D50
81 – 150 0 q8hrs
151 – 200 2 q4hrs
201 – 250 4 q2hrs
251 – 300 6 q2hrs
301 – 350 8 qhourly
351 – 400 10 qhourly
>400 12 Refer
Insulin Regimens
NPH Insulin + Regular Insulin

Total Insulin = 0.5 to 1 U/kg Body Weight


2/3 total 1/3 total
insulin insulin
2/3 NPH 1/2 NPH
1/3 1/2
Regular Regular
Sugar Pre- Pre-lunch Pre-supper Before
breakfast sleeping
Adjust Pre-super Pre- Pre- Pre-
NPH breakfast breakfast supper
Regular NPH Regular

Glargine Insulin + Lispro Insulin

Total Insulin = 0.5 to 1 U/kg Body Weight


1/2 total 1/2 total
insulin insulin
1/3 Lispro 1/3 Lispro 1/3 Lispro Glargine
Sugar Pre- Pre-lunch Pre- Before
breakfast supper sleeping
Adjust Glargine Pre- Pre- Pre-supper
breakfast breakfast Lispro
Lispro Lispro

 Inpatient goals
 Pre-prandial 90-130 mg/dL
 Post-prandial < 180 mg/dL
 For thin, insulin sensitive patients
 Add 1 unit to errant insulin for every 50 mg/dL above
target
 For obese, insulin resistant patients
 Add 2 units to errant insulin for every 50 mg/dL
above target
DM – Outpatient
 Diagnostics:
 FBS, 2-hour post-prandial glucose
 Lipid profile
 HBA1c
 Targets
 HBA1c < 7%
 Pre-prandial glucose (FBS) 70-130 mg/dL
 Post-prandial glucose (2h PPBS) < 180 mg/dL
 BP < 140/90
 Lipid modification (order of decreasing priority)
 LDL < 100 mg/dL
 HDL > 40 mg/dL in males, > 50 in females
 TG < 150 mg/dL
 Medications: Biguanides
 Dose
 Metformin 500 mg-1g OD, BID, TID (max 3g/day)
 Adjust every 2-3 weeks
 Goal effect
 Reduces HBA1c by 1-2%
 Reduces fasting plasma glucose
 Good: weight loss
 Caution: Renal insufficiency (Crea > 124 mmol/L),
lactic acidosis, GI effects
 Hold 24h prior to procedures, while critically ill
 Medications: Sulfonylureas
 Dose
 Glimepiride 1-8 mg OD
 Glipizide 2.5-10 mg OD-BID
 Take shortly before meals
 Goal effect
 Reduces HBA1c by 1-2%
 Reduces fasting and post-prandial plasma glucose
 Caution: weight gain, hypoglycemia, renal
insufficiency (Crea > 124 mmol/L), liver disease
 Medications: Thiazolidinediones
 Dose
 Pioglitazone 15-45 mg OD
 Rosiglitazone 1-4 mg OD-BID
 Goal effect
 Reduces HBA1c by 0.5-1.5%
 Reduces fasting and post-prandial plasma glucose
 Reduces insulin requirements
 Caution: weight gain but redistributes to peripheral
areas, hypoglycemia, renal insufficiency (Crea > 124
mmol/L), liver disease, edema, heart failure
 Medications: DPP-IV inhibitors
 Dose
 Sitagliptin 50-100 mg OD
 Vildagliptin 50 mg OD-BID
 Goal effect
 Reduces HBA1c by 0.5-1.0%
 Reduces insulin requirements
 Good: does not cause weight gain, minimal
hypoglycemia
 Caution: Renal insufficiency (use 50 mg OD if Crea
>124 mmol/L), headache, diarrhea, URTI
 Medications: Alpha-glucosidase inhibitors
 Dose
 Acarbose 25 mg with evening meal
 Maximize to 50 - 100 mg with every meal
 Goal effect
 Reduces HBA1c by 0.5-0.8%
 Reduces post-prandial plasma glucose
 Good: weight loss
 Caution: GI effects (diarrhea, flatulence, abdominal
distention), Renal insufficiency (Crea > 177 mmol/L)
 Medications
 If 2 drugs aren’t sufficient, insulin is recommended
 Cost and compliance are of prime importance
 Diet
 Fat 20-35%
 Minimal saturated fat (<7%)
 Minimal transfat
 Decreased cholesterol (<200 mg/d)
 At least 2 servings of fish (Omega-3 fatty acids)
 Carbohydrates 45-65%
 Low glycemic index
 Sucrose containing food with adjustments in
meds/insulin
 Protein 10-35%
 High fiber
 Exercise at least 150 minutes/week
 Monitor blood sugar before, during and after
 exercise
 CBG > 250 mg/dL, delay exercise
 CBG < 100 mg/dL, eat carbohydrate before exercise
 Pre-exercise insulin modification
 Decrease dose
 Inject into non-exercising muscle
 Follow-up
 Home monitoring of glucose
 HbA1c q3-6 months
 Medical nutrition therapy and education
 Eye examination annually
 Foot examination daily by patient, annually by MD
 Screening for albuminuria annually
 Lipid profile and Crea annually
 BP measurement q4 months
Thyroid Disease
 Hyperthyroidism
 Hypothyroidism

Hyperthyroidism
Symptoms
 Hyperactivity, irritability
 Heat intolerance, sweating
 Palpitations
 Weakness, weight loss, diarrhea
 Polyuria, oligomenorrhea
Signs
 Tachycardia, sometimes atrial fibrillation
 Warm, moist skin
 Tremors, muscle weakness
 Anterior neck mass

 Diagnostics
 CBC with PC (infection)
 12-L ECG (atrial fibrillation, tachycardia)
 Chest X-ray (rule out infection, cardiomegaly)
 Urinalysis (infection)
 Free T4 and TSH (high FT4, low TSH)
 Crea, Na, K (low K)
 Thyroid UTZ (especially if with nodule/s)
 Burch-Wartofsky scoring

 Score
 25-44: impending storm
 ≥45: storm
 Therapeutics
 Propylthiouracil 600 mg LD then 200-300 mg q6hrs
 Orally/NGT
 By rectum
 Saturated solution of Potassium Iodide (SSKI) 5 drops
q6-8hrs, 1 hour after every PTU dose
 Propranolol 40-60 mg PO q4hrs
 If still no rate control: Verapamil 2.5-5 mg SIVP q15-
30mins, maximum of 20 mg
 Use digoxin rarely (decreased potency in
hyperthyroidism)
 Glucocorticoids
 Dexamethasone 2 mg IV q6
 Hydrocortisone 50 mg IV q6
 Treat infection, fever aggressively
 Correct electrolytes
 ICU admission
 If stable, may admit to Ward
 Refer to Endo

Resolution
 Discharge
 Taper PTU to 200 mg TID
 Heart rate controlled with Propranolol BID
 Infection/precipitant treated
Hyperthyroidism - Out-patient
 Medication adjustment
 Preferably Methimazole 20-30 mg OD
 Taper Propranolol until PRN
 Follow-up
 2-4 weeks with repeat FT4 (same laboratory)
 Adjust methimazole based on FT4
 TSH may be taken eventually to prove suppression
 Dietary avoidance
 Seafood
 Iodized salt
 30 to 50% achieve remission on medical treatment
alone
 Usually after 12-18 months
 Definitive treatment: once euthyroid
 RAI
 Surgery
 Refer to Endo and GS/ORL

Watch out for…


 Ophthalmopathy
 Steroids
 Prednisone 1 mg/kg in 2 divided doses
 Artificial tears
 Smoking cessation
 Refer to Ophtha
Hypothyroidism
Symptoms
 Weakness
 Dry skin, hair loss, impaired healing
 Difficulty concentrating
 Weight gain, poor appetite
 Heart failure
Signs
 Dry coarse skin, cool peripheral extremities
 Puffy face, hands and feet; alopecia
 Bradycardia
 Serous cavity effusions (pericardial, pleural,
peritoneal)
 Hyporeflexia

 Diagnostics
 Free T4, TSH (low FT4, High TSH)
 CBC with PC
 12-L ECG (documentation of heart rate)
 Chest X-ray (enlarged heart, pleural effusion)
 Crea, Na, K (hypokalemia)
 Thyroid UTZ
 Anti-TPO
 Therapeutics
 Levothyroxine 1.6 ug/kg BW in single dose before
breakfast
 If missed dose: may take 2-3 doses of skipped tablets
at once due to long half-life
 Follow-up
 Repeat TSH after 2-4 weeks
 Use same laboratory
 Target lower half of TSH range
Gastroenterology
Doctors’ Guide
Peptic Ulcer Disease
Symptoms
 PUD: Epigastric pain, usually at night
 Metallic/acid taste in the mouth
 Melena
 NSAID use
 Weight loss, early satiety, vomiting
Signs
 Epigastric tenderness
 Epigastric mass
 Melena on DRE (uncommon)

 Diagnostics
 CBC with PC
 EGD with H. pylori biopsy
 Urea breath test
 FOBT
 Chest X-ray
 Therapeutics (Active Bleeding)
 PPI drip
 Omeprazole 80 mg IV bolus
 Omeprazole 80 mg in pNSS to make 100 cc x 10
cc/h (8mg/h)
 Immediate endoscopy
 Therapeutics
 Proton pump inhibitors – 2-week trial
 Omeprazole 20 mg/d
 Esomeprazole 20 mg/d
 Lansoprazole 30 mg/d
 Administer BEFORE a meal
 Long-term: pneumonia, osteoporosis
 H2-receptor antagonists
 Ranitidine 300 mg @HS
 Famotidine 40 mg @HS
 Antacids
 Usually for symptom relief
 Aluminum hydroxide-Magnesium hydroxide
 WOF nephrotoxicity
 Therapeutics (H. pylori positive)
 OCA/OCM regimen
 Omeprazole 20 mg BID
 Clarithromycin 250-500 mg BID
 Amoxicillin 1g BID OR
 Metronidazole 500 mg BID
 Refer to GI if no response
 Follow-up
 after 2-4 weeks
 Decision to continue PPI dependent on symptoms
 Gastric ulcers have risk for malignancy
Gastroesophageal reflux disease
Symptoms
 Burning retrosternal chest pain
worsening/precipitated by recumbency
 Regurgitation of sour material into mouth
 Cough
 Dysphagia
Signs
 Obesity
 Usually normal abdominal PE

 Diagnostics
 Usually none needed
 EGD
 CBC with PC
 Therapeutics
 Proton-pump inhibitors
 Omeprazole 20 mg/d
 Esomeprazole 40 mg/d
 Take 30 minutes before breakfast
 Weight reduction
 Elevation of head by 4-6 inches during recumbency
 Avoid
 Smoking
 Fatty food, large quantities of food/fluid
 Alcohol, mint, orange juice
 Calcium channel blockers
Toxicology
Doctors’ Guide
General Principles of Management
 Emergency Stabilization
 Airway
 Breathing: Oxygenation and Ventilation
 Circulation: Inotropes
 Convulsion cessation
 Electrolyte/metabolic correction
 Coma
 Clinical Evaluation
 History:
 Time, Mode/Route
 Circumstances prior
 Pre-existing illnesses or co-morbidities
 Home remedies/treatment given
 Physical Exam:
 Complete
 Breath odor
 Neurologic PE
 Laboratory Examinations
 CBC with PC
 Urinalysis
 RBS, BUN, Creatinine, Na, K, Ca, alb, Mg
 ABG
 12-L ECG
 Bilirubins, PT, AST, ALT, Alk Phos
 Chest X-ray (best if PA-upright)
 Plain abdominal X-ray
 Elimination of the poison
 External decontamination
 Discard all clothing
 Thorough bathing
 Eye irrigation
 Protective gear for personnel
 Empty stomach
 Induction of emesis (if ingestion occurred within 1 hour)
 Gastric Lavage (50-60 mL of tepid sterile water)
 Don’t do in ingestion of caustics, kerosene!
 Don’t do if patient is convulsing!
 Limit GI absorption
 Activated charcoal: 50-100 g in 200 mL H2O
 Do multiple doses if with enterohepatic recirculation
 Contraindicated in caustics
 Follow with Na sulfate up to 2 doses, then soap sud
enema for BM
 Demulcent agents
 Raw egg albumin: whites of 8-12 eggs
 Cathartics
 Na sulfate 15 g in 100 mL H2O
 Contraindicated in caustics, easily absorbable
chemicals, ileus, severe fluid and electrolyte imbalances
 Excretion of absorbed substances
 Forced diuresis
 Mannitol 20% 1 mL/kg within 10 minutes then 2.5-5 mL/kg
q6 x 8 doses
 Must have good urine output
 Alkalinization (for weak acids)
 NaHCO3 1mEq/kg/dose IV targeting urine pH > 7.5
 Acidification (for weak bases)
 Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5
 Dialysis
 Antidotes
 Supportive Therapy
 Fluid replacement for losses
 Electrolyte correction
 Prevention of aspiration, decubitus ulcers
 Monitoring VS and I/O
 Disposition
 ER vs Ward vs ICU
 Psychiatric evaluation
 Social evaluation
Alcohol Intoxication
 Blood alcohol (mg/dL)

))
 Metabolism
 Non-alcoholic: 13 to 25 mg/dL per hour
 Alcoholic: 30 mg/dL per hour
 Estimated time of recovery
 Blood alcohol/metabolic rate

Blood Symptoms Brain affected


ethanol
(mg/dL)
< 50 Talkativeness, euphoria Frontal lobe
Decreased inhibition /
50 – 100 Parietal lobe
increased confidence
Ataxia, slurred speech, Occipital lobe,
100 – 300
diplopia cerebellum
Visual impairment, severe
300 – 500 Midbrain
ataxia, stupor
> 500 Respiratory failure, coma Medulla

Percent Ethanol
Category Specific %Ethanol
Lager 2 – 3%
Beer Pilson 5 – 6%
Strong 9 -14%
Wine Red/White 7 – 12%
Fortified wine Champagne 15 – 20%
Whiskey, rye, rhum, bourbon, 40 – 50%
Distillates
gin
Local distilled Lambanog, tuba 60 – 80%
Hygiene Perfume/cologne 25 – 95%
Products Mouth wash 15 – 25%
History
 Amount ingested
 With what substance
PE
 Evidence of trauma
 Level of sensorium

 Diagnostics
 Urine ketones
 CK MB, MM
 Amylase
 FOBT
 Therapeutics
 NPO
 Insert NGT
 IVF: D5 0.9 NaCl 1L x 8h
Conscious
 Therapeutics
 Thiamine 100 mg IM/IV
 D50-50 100 mL fast drip IV
 Refer to Psych
 Evaluate for withdrawal
 Observe for 6 hours
 Discharge on
 Thiamine 50 mg TID OR
 Vitamin B complex 1 tab TID
 Folic Acid OD, Multivitamins OD
Unconscious
 Therapeutics
 Thiamine 100 mg IM/IV now then q8
 D50-50 100 mL fast drip IV
 Refer to Neurology
 Observe for return of consciousness
 Fully awake: Observe for 5-7 days, refer to
Psychiatry
 Partially awake: Work-up for decreased sensorium
(NSS?)
 Comatose: Naloxone 2 mg IV q2 minutes for a
total of 10mg; work-up for decreased sensorium,
consider HD
 Same discharge plans

Alcohol Withdrawal
Symptoms/Signs
 Autonomic hyperactivity (sweating, tachycardia)
 Increased tremors
 Insomnia
 Nausea/vomiting
 Hallucinations/illusions
 Psychomotor agitation/anxiety
 Seizures

 Therapeutics
 Diazepam 2.5-5mg q8 x 3 days then taper for next
2days before discontinuation
 Vitamin B complex TID
 Folic Acid OD

Resolution
 Enroll in quitting program
 Advice moderation
Paracetamol
 Toxic dose if 150-300 mg/kg
 Symptoms vary based on time after exposure
 0-24 hours: asymptomatic, nausea, vomiting
 24-36 hours: asymptomatic, upper abdominal pain
 36-72 hours: onset of liver/renal failure
 72-120 hours: jaundice, bleeding, liver/renal failure
History
 Time, mode
 Intake of other substances/meds
 Co-morbidities
Physical Exam
 Heart, liver, kidneys
 Neurologic examination
 Diagnostics
 Serum paracetamol
 AST, ALT, PT
Watch out for…
 Acute Renal Failure
 IVF hydration
 Refer to Renal for possible Dialysis
 Bleeding
 Vitamin K 10 mg IV up to q6
 Target PT > 60% activity
 Hepatic insufficiency
 Vitamin B complex
 Vitamin K
 Electrolyte abnormalities
 Hypoglycemia, acidosis, hypokalemia,
hypocalcemia
Silver Jewelry Cleaner
 Active compound is cyanide-derived
 Binds to cytochrome oxidase enzymes, inhibiting
cellular respiration
SJC: Order Sheet
 Diagnostics
 ABG
 Serum cyanide
 CBC with PC
 Anticipatory Care
 ICU admission
 Close monitoring
 Treatment for co-ingestants (e.g. alcohol)
 Therapeutics
 Oxygenation
 High flow
 Prophylactic intubation esp. if with decreased
sensorium
 Na nitrite 300 mg SIVP (over 5 minutes)
 Vasodilator, displaces cyanide, producing
methemoglobin
 Causes hypotension
 Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP
(over 10 minutes)
 Speeds the displacement of cyanide by providing
sulfur for binding
Watch out for…
 Decreased sensorium
 Aspiration precautions
 Prophylactic intubation if warranted
 Seizures
 Diazepam
 Increased oxygen delivery
 Hypoxic encephalopathy
 Rapidly reversible if antidote given early
 If still not reversed, need prognostication by Neuro
Kerosene
History
 Time
 Amount
 Mucous membrane irritation
 CNS depression, seizures
Physical Exam
 Lung findings: crackles, respiratory distress
 Arrhythmia, tachycardia
 Sensorial changes
 Diagnostics
 Chest X-ray (6 hours post-ingestion)
 ABG
Watch out for…
 Pneumonia
 Penicillin G 200,000 u/kg/d in 6 divided doses
 Clindamycin 300 mg PO/IV q6
 Metronidazole 500 mg PO/IV q6
 Gastritis
 Al-hydroxide-Mg-hydroxide 30 mL q6
 Prolonged PT
 Vitamin K 10 mg OD
 Seizures
 Diazepam 2.5-5 mg SIVP
 Refer to Neuro
Acids
 Causes coagulation necrosis which forms eschars
 Damage is self-limiting
 Eventual stenosis of viscus

 Diagnostics
 Cross-matching
 Urine hemoglobin
 Chest X-ray upright, plain abdomen
 Emergency EGD
 Therapeutics
 Copious amounts of water to decontaminate
externally
 NPO
 IVF: D5NSS 1L x 8h
 Meperidine 25-50 mg IM
 Famotidine 20 mg IV q12
 Concentrated acids: Enhance excretion with
Mannitol
 Test dose: 1 mL/kg within 10 mins
 If with good urine output: 2.5-5.0 mL/kg q6 x 8
doses
 Discontinue mannitol if with poor urine output x 2h

Grade Findings
0 Normal
1 Edema, hyperemia of mucosa
Friability, blisters, hemorrhages, erosions, whitish
2A
membranes, exudates, superficial ulcerations
2B 2A + deep discrete or circumferential ulceration
Small scattered areas of multiple ulcerations and
3A
areas of necrosis
3B Extensive necrosis
Watch out for…
 Acute abdomen
 Surgery
 Lifelong vitamin B12 if gastrectomy done
 Shock
 Fluids, antibiotics as appropriate
 Upper airway obstruction
 Tracheostomy
 Hydrocortisone 100 mg IV q6
 Upper GI Bleed
 Blood transfusion, surgery
Alkali
 Causes liquefaction necrosis
 Damage spreads, and may continue for days

 Diagnostics
 Cross-matching
 Urine hemoglobin
 Chest X-ray upright, plain abdomen
 Emergency EGD
 Therapeutics
 Copious amounts of water to decontaminate
externally
 NPO
 IVF: D5NSS 1L x 8h
 Meperidine 25-50 mg IM
 Famotidine 20 mg IV q12

Extent Findings
First Superficial mucosal hyperemia, mucosal
degree edema, superficial sloughing
Deeper tissue damage, transmucosal (all
Second
layers of the esophagus), with exudates,
degree
erosions
Through the esophagus and into the
Third periesophageal tissues (mediastinum, pleura or
degree peritoneum), deep ulcerations, black
coagulum
Watch out for…
 Acute abdomen
 Surgery
 Lifelong vitamin B12 if gastrectomy done
 Shock
 Hypovolemic/Septic: Fluids, antibiotics as
appropriate
 Neurogenic: Mepedirine 1 mg/kg/dose IV
 Upper airway obstruction (Glottic edema)
 Tracheostomy
 Hydrocortisone 100 mg IV q6
 Upper GI Bleed
 Blood transfusion, surgery
Organophosphate

Sample Order
 Please admit patient
 Secure consent
 Insert NGT now
 NPO
 O2 inhalation via facemask at 6LPM
 IVF double line:
 1st Line: PNSS 1L as Fast drip at Right hand
 2nd Line: PLR 1L as Fast drip at Left hand
 Monitor V/S Q4hrs
 Make a table to monitor Q2hrs the following
parameters:
 Mucosa
 HR
 Bowel sounds
 Pupillary size
 Diagnostics - STAT
 CBC plt
 Serum Crea, K, Na
 ABG
 CBG
 AST, ALT
 Protein
 U/A
 CXR PA
 12L ECG
 Management
 Decontamination
 Have patient take a bath with soap and water
 Change clothes
 Activated charcoal 50mg per NGT now, then
Sodium sulfate 15-30 grams in water after 30mins
 Repeat Sodium sulfate 15-30 grams in water after
1hour if no BM
 Antidote:
 Atropine sulfate 0.5mg IVTT now then Q5mins for 2
more doses to achieve HR >60bpm (target normal
100bpm)
 Diazepam 5mg IVTT Q8hrs PRN for seizure
 CBG monitoring Q6hr while on NPO
National Poison Control and Management
Center
 (O2) 554-8400 loc 2311
 (O2) 524-1078
 0922-896-1541
PEDIATRICS NOTES
Doctors’ Guide
History & Physical
Examination
Doctors’ Guide
H.E.A.D.S.S.S.

Home Environment
 With whom does the adolescent live?
 Any recent changes in the living situation?
 How are things among siblings?
 Are parents employed?
 Are there things in the family he/she wants to
change?
Employment and Education
 Currently at school? Favorite subjects?
 Patient performing academically?
 Have been truant / expelled from school?
 Problems with classmates/teachers?
 Currently employed?
 Future education/employment goals?
Activities
 What he/she does in spare time?
 Patient does for fun?
 Whom does patient spend spare time?
 Hobbies, interests, close friends?
Drugs
 Used tobacco/alcohol/steroids?
 Illicit drugs? Frequency? Amount?
 Affected daily activities?
 Still using? Friends using/selling?
Sexual activities
 Sexual orientation?
 GF/BF? Typical date?
 Sexually active? When started? # of persons?
 Contraceptives? Pregnancies? STDs?
Suicide/Depression
 Ever sad/tearful/unmotivated/hopeless?
 Thought of hurting self/others?
 Suicide plans?
Safety
 Use seatbelts/helmets?
 Enter into high risk situations?
 Member of frat/sorority/orgs?
 Firearm at home?
F.R.I.C.H.M.O.N.D

 Fluids
 Respiration
 Infection
 Cardiac
 Hematologic
 Metabolic
 Output & Input (cc/kg/h) N: 1-2
 Neuro
 Diet

Nutrition

AGE WT. CAL CHON


0-5 mo 3-6 115 3.5
8-11 mo 7-9 110 3.0
1-2 yr 10-12 110 2.5
3-6 yr 14-18 90-100 2.0
7-9 yr 22-24 80-90 1.5
10-12 yr 28-32 70-80 1.5
13-15 yr 36-44 55-65 1.5
16-19 yr 48-55 45-50 1.2

TCR β : Weight at p50 x calories


TCR : CHON x ABW
Total Caloric intake : calories x amount of intake
(oz)
Gastric capacity : age in months + 2
Gastric emptying time : 2 – 3 hours
Vital Sign

Body Temperature
Subnormal <36.6°C
Normal 37.4°C
Subfebrile 35.7 – 38.0°C
Fever 38.0°C
High fever >39.5°C
Hyperpyrexia >42.0°C

AGE HR (bpm) BP (mmHg) RR (cpm)


Systolic Diastolic
Preterm 120 – 170 55 – 75 35 – 45 40 – 70
Term 120 – 160 65 – 85 45 – 55 30 – 60
0 – 3 mo 100 – 150 65 – 85 45 – 55 35 – 55
3 – 6 mo 90 – 120 70 – 90 50 – 65 30 – 45
6 – 12 mo 80 – 120 80 – 100 55 – 65 25 – 40
1 – 3 yrs 70 – 110 90 – 105 55 – 70 20 – 30
3 – 6 yrs 65 – 110 95 – 110 60 – 75 20 – 25
6 – 12 yrs 60 – 95 100 – 120 60 – 75 14 – 22
12 – 17 yrs 55 – 85 110 – 135 65 – 85 12 – 18

 BP cuff should cover 2/3 of arm


SMALL cuff : falsely high BP
LARGE cuff : falsely low BP

Anthropometric Measurements

Body Mass Index

Asian Caucasian
Underweight < 18.5 < 18.5
Normal 18.5 – 22.9 18.5 – 24.9
Overweight ≥ 23.0 25 – 29.9
At risk 23 – 24.9
Obese I 25 – 29.9 30 – 39.9
Obese II ≥ 30.0 ≥ 40.0

Ideal Body Height

Age Kilograms Pounds


3 kg (Fil)
At birth 7
3.35 kg (Cau)
Age (mo) + 10 (Fil)
3 – 12 months Age (mo) + 9/2
Age (mo) + 11 (Cau)
1 – 6 years Age (y) x 2 + 8 Age (y) x 5 + 17
7 – 12 years Age (y) x 7 – 5/2 Age (y) x 7 + 5

Given Birth Weight:


Age Using Birth Weight in Grams
< 6 months Age (mo) x 600 + birth weight (gm)
6 – 12 months Age (mo) x 500 + birth weight (gm)

Expected Body Weight (EBW):


Age Ideal Weight
Term Age in days – 10 x 20 + Birth Weight
Pre-term Age in days – 14 x 15 + Birth Weight
4 – 5 months 2 x Birth Weight
1 year 3 x Birth Weight
2 years 4 x Birth Weight
3 years 5 x Birth Weight
5 years 6 x Birth Weight
7 years 7 x Birth Weight
10 years 10 x Birth Weight
Length / Height

Age Centimeters Inches


At birth 50 20
1 year 75 30
2 – 12 years Age x 6 + 77 Age x 2.5 + 30

Age Gain in 1st Year is ~25cm


0 – 3 months + 9 cm 3 cm per mo
3 – 6 months + 8 cm 2.67 cm per mo
6 – 9 months + 5 cm 1.6 cm per mo
9 – 12 months + 3 cm 1 cm per mo

Head Circumference

Age Centimeters Inches


At birth 35 cm 13.8 in
< 4 mo + 5.08 cm + 2 in
(1.27 cm/mo) (1/2 inches/mo)
5 – 12 mo + 5.08 cm + 2 in
(0.635 cm/mo) (1/4 inches/mo)
1 – 2 yr + 2.54 cm + 1 in
3 – 5 yr + 3.81 cm + 1.5 in
(1.27 cm/mo) (1/2 inches/yr)
6 – 20 yr + 3.81 cm + 1.5 in
(1.27 cm/mo) (1/2 inches/yr)

Fontanels

Appropriate size at birth : 2 x 2 cm (anterior)


Closes at: Anterior : 18 months or as early as 9-
12months
Posterior : 6 – weeks or
2 – 4 months
Thoracic Index

Age Transverse – AP
Inches
Diameter Ratio
At birth 1.0 Transverse = AP
1 year 1.25 Transverse > AP
6 year 1.35 Transverse >>> AP

APGAR Score

0 1 2
Pink body / Blue
A Blue / Pale Completely pink
extremities
P Absent Slow (<100) > 100
(-) Coughs, sneezes,
G Grimaces
Response cries
(-) Some flexion / Active
A
Movement extension movement
R Absent Slow / irregular Good, strong cry

8 – 10 : Normal
4–7 : Mild / Moderate Asphyxia
0–3 : Severe Asphyxia
Glasgow Come Scale (GCS)

Age 0 – 1 year Age 1 year or older


4 Spontaneous 4 Spontaneous
Opening

3 To shout 3 To verbal command


Eye

2 To pain 2 To pain
1 None 1 None
6 Spontaneous 6 Obeys command
5 Localize pain 5 Localize pain
Motor

4 Withdraw 4 Withdraw
3 Flexion 3 Flexion
2 Extension 2 Extension
1 None 1 None

Age 0 – 2 years Age 2 – 5 years Age > 5 years


Cries Appropriate
5 5 5 Oriented
appropriately words
Cries Inappropriate
4 4 4 Disoriented
Inappropriate words
Verbal

Crying / Inappropriate
3 3 Screaming 3
screaming words; cries
Incomprehensible
2 Grunts 2 Grunts 2
words
1 None 1 None 1 None
Tanner Stages

Pubic hair growth in FEMALES is staged as follows


 Stage I (Preadolescent)
 Vellos hair develops over the pubes in a manner not
greater than that over the anterior wall. There is no
sexual hair.
 Stage II
 Sparse, long, pigmented, downy hair, which is
straight or only slightly curled, appears. These hairs
are seen mainly along the labia. This stage is difficult
to quantitate on black and white photographs,
particularly when pictures are of fair-haired subjects.
 Stage III
 Considerably darker, coarser, and curlier sexual hair
appears. The hair has now spread sparsely over the
junction of the pubes.
 Stage IV
 The hair distribution is adult in type but decreased in
total quantity. There is no spread to the medial
surface of the thighs.
 Stage V
 Hair is adult in quantity and type and appears to
have an inverse triangle of the classically feminine
type. There is spread to the medial surface of the
thighs but not above the base of the inverse
triangle.
The stages in MALE pubic hair development are as follows
 Stage I (Preadolescent)
 Vellos hair appears over the pubes with a degree of
development similar to that over the abdominal
wall. There is no androgen-sensitive pubic hair.
 Stage II
 There is sparse development of long pigmented
downy hair, which is only slightly curled or straight.
The hair is seen chiefly at the base of penis. This
stage may be difficult to evaluate on a photograph,
especially if the subject has fair hair.
 Stage III
 The pubic hair is considerably darker, coarser, and
curlier. The distribution is now spread over the
junction of the pubes, and at this point that hair may
be recognized easily on black and white
photographs.
 Stage IV
 The hair distribution is now adult in type but still is
considerably less that seen in adults. There is no
spread to the medial surface of the thighs.
 Stage V
 Hair distribution is adult in quantity and type and is
described in the inverse triangle. There can be
spread to the medial surface of the thighs.
In young WOMEN, the Tanner stages for breast
development are as follows
 Stage I (Preadolescent)
 Only the papilla is elevated above the level of the
chest wall.
 Stage II (Breast Budding)
 Elevation of the breasts and papillae may occur as
small mounds along with some increased diameter
of the areolae.
 Stage III
 The breasts and areolae continue to enlarge,
although they show no separation of contour.
 Stage IV
 The areolae and papillae elevate above the level of
the breasts and form secondary mounds with further
development of the overall breast tissue.
 Stage V
 Mature female breasts have developed. The
papillae may extend slightly above the contour of
the breasts as the result of the recession of the
aerolae.
The stages for male genitalia development are as follows:
 Stage I (Preadolescent)
 The testes, scrotal sac, and penis have a size and
proportion similar to those seen in early childhood.
 Stage II
 There is enlargement of the scrotum and testes and
a change in the texture of the scrotal skin. The
scrotal skin may also be reddened, a finding not
obvious when viewed on a black and white
photograph.
 Stage III
 Further growth of the penis has occurred, initially in
length, although with some increase in
circumference. There also is increased growth of the
testes and scrotum.
 Stage IV
 The penis is significantly enlarged in length and
circumference, with further development of the
glans penis. The testes and scrotum continue to
enlarge, and there is distinct darkening of the scrotal
skin. This is difficult to evaluate on a black-and-white
photograph.
 Stage V
 The genitalia are adult with regard to size and
shape.
Immunization
Doctors’ Guide
Expanded Program on Immunization

Vaccine Age Dose No. Route Site Interval


0.05mL
(NB) R-
BCG-1 Birth or 6 wks 1 ID
0.1mL deltoid
(older)
Upper
DPT 6 wks 0.5mL 3 IM outer 4 wks
thigh
OPV 6 wks 2 drops 3 PO Mouth 4 wks
Antero-
HEPA B 6 wks 0.5mL 3 IM lateral 4 wks
thigh
Outer
MEASLES 9 mos 0.5mL 1 SC upper 4 wks
arm
L-
BCG-2 School entry 0.1mL 1 ID
deltoid
1 mo
Childbearing
TetToxoid 0.5mL 3 IM Deltoid then 6-
women
12 mos

Adverse Reactions From Vaccines

Vaccine Adverse reaction


BCG 1. Wheal ► small ► abscess ► ulceration ► healing /
scar formation in 12 wks
2. Deep abscess formation, indolent ulceration, glandular
enlargement, suppurative lymphadenitis
DPT 1. Fever, local soreness
2. Convulsions, encephalitis / encephalopathy,
permanent brain damage
OPV Paralytic Polio
HEPA B Local soreness
MEASLES 1. Fever & mild rash
2. Convulsions, encephalitis / encephalopathy, SSPE,
death
Type of Immunization

Active Passive
BCG Diphtheria
DPT Tetanus
OPV Tetanus Ig
Hep B Measles Ig
Measles Rabies (HRIg)
Hib Hep A Ig
MMR Hep B ig
Tetanus Toxoid Rubella Ig
Varicella
Intravenous Fluid
Doctors’ Guide
Selection of Fluids

Fluid of
Condition Need to supply Comments
Choice
Diarrhea
 Loss of water &  Water & Plain LR  May shift to D5LR
electrolyte electrolyte if patient is
 Loss of K thru  K already hydrated
GIT  Bicarbonate /  May use D3LR if
 Metabolic Lactate patient has poor
Acidosis intake
Shock
 Loss of water &  Water & Plain LR  PNSS/ 0.9% NaCl
electrolyte electrolyte (bolus) is an alternative
 Metabolic choice, but one
Acidosis must watch out
for
hyperchloremic
acidosis
Vomiting
 Loss of water &  Water & Plain  If committing
electrolyte electrolyte NSS / progresses K loss
 Metabolic 0.9% must be
Acidosis NaCl replaced. Plain LR
can be the
alternative
choice
Initial Post-op
Maintenance  Water & D5LR  Avoid blousing
 Loss of water & electrolyte with Dextrose
electrolyte  Dextrose  May use D5NS as
 NPO an alternative
Hypotonic
Maintenance  Water & D5IMB  Should not be
 Low K electrolyte D5NM used for hydration
 K
 Dextrose
Hypotonic
Maintenance  Water & D5  Usually used for
 Normal/slight electrolyte 0.3NaCl cardiac and
high Na  Dextrose hema-once
 Normal/slight patients
high K
 Risk for high K
Holiday-Segar Formula

Weight (kg) Formula Example


Wt = 8 kg
100 x 8
0 – 10 100 cc/kg/24
24
Ans: 33 ugtts/min
Wt = 13 kg
(Wt – 10) x 50 + 1000 (13 – 10) x 50 + 1000
11 – 20
24 24
Ans: 48 ugtts/min
Wt = 24 kg
(Wt – 20) x 20 + 1500 (24 – 20) x 20 + 1500
Above 20
24 24
Ans: 66 ugtts/min

Alternative (Ludan’s Method)

Weight (kg) Formula Example


Wt = 8 kg
3 – 10 100 cc/kg/24 100 cc x 8 kg / 24 hrs
Ans: 33 ugtts/min
Wt = 13 kg
0 – 3 and
75 cc/kg/24 75 cc x 13 kg / 24 hrs
11 – 20
Ans: 40 ugtts/min
Wt = 24 kg
21 - 30 50-60 cc/kg/24 50 cc x 24 kg / 24 hrs
Ans: 50 ugtts/min
Wt = 32 kg
31 - 60 40-50 cc/kg/24 40 cc x 32 kg / 24 hrs
Ans: 53 ugtts/min
Conversion of microdrops (ugtts) to macrodrop (gtts)

 Facts: 1 gtts is equal to 4 ugtts Conversion:


 Microdrops to macrodrop
 Formula:
 ugtts x 1 gtts/4 ugtts OR
 ugtts/4
 Example: the computation reveals 88ugtts/min
 88uggts/4
 Answer: 22 gtts/min
NOTE: this conversion is commonly used in Dengue Cases.

A. Factors that lead to possible modification of IV


maintenance rate

 Need Extra Fluid


 Temperature: for every degree increase from normal
body temperature 10-12% may be added to the
total fluid requirement (TFR) for 24 hours.
 Tachypnea for age: 20-30% may be added to the
TFR in 24 hours.
 In Pneumonia where we usually found both fever
and tachypnea, we increase our TFR by 30-32%.
 Phototherapy: 20% of the fluid is added to the TFR
 Need Lesser Fluid
 Hypothermia: less 12% per each degree Celsius
below 37.5
 Humidified inspired air: less 25%
 Sedation or paralyzed: less 40% (due to decrease
energy expenditure)
 Edematous/Congestion: 25 – 35% less
NOTE: The decision to modify the IV maintenance rate shall
depend on the accurate assessment of the case. We
should always be concern about fluid overload.
Pulmonology
Doctors’ Guide
Pneumonia in Children
Definition:
 Pneumonia is an inflammation of lung parenchyma
Incidence:
 15 million deaths worldwide
 95% from developing countries
Etiology:
 Community Acquired Pneumonia
 0 – 2 months
 Gram (-) bacilli
 3 months – 5 years
 H. influenzea, S. pneumoniae, S. aureus
 5 years
 S. pneumoniae
 Atypical Pneumonia
 Mycoplasma spp, Chlamydia spp
 Aspiration Pneumonia
 Anaerobic, Streptococci, Gram (-) bacilli
 Nosocomial Pneumonia
 Gram (-) bacilli, Pseudomonas, S. Aureus
 Empyema
 S. aureus, S. pneumoniae, S. pyogenes
 Lung abscess
 Anaerobes, S. aureus, Streptococcus spp
 Pleural effusion
 S. aureus, Streptococcus spp, TB bacilli
Revised Risk Classification for Pneumonia
CLASSIFICATION PROVIDED BY
PAPP PCAP A or B PCAP-C PCAP-D
PhilHealth --- Pneumonia I Pneumonia II
WHO No
Severe Very Severe
pneumonia/
Pneumonia Pneumonia
pneumonia
Clinical
1. Dehydration None or mild Moderate Severe
2. Malnutrition None Moderate Severe
3. Pallor None Present Present
4. Respiratory Rate
≥ 50/min to ≥ 60/min to
a. 3 – 12 mos >70/min
≤60/min ≤70/min
≥ 40/min to
b. 1 – 5 yrs > 50/min >50/min
≤50/min
≥ 30/min to
c. > 5 yrs >35/min >35/min
≤35/min
5. Sx of Respiratory
Failure
Supraclavicular
a. Retraction None IC/Subcostal
/ IC / SC
b. Head bobbing None Present Present
c. Cyanosis None Present Present
d. Grunting None None Present
e. Apnea None None Present
Lethargic to
f. Sensorium None Irritable
coma
Diagnostic aid at side-of-care
1. CXR findings of
any: Effusion,
Abscess, Air None Present Present
leak, Lobar
consolidation
2. O2 sat at room
95% <95% <95%
air
 At least 2 variables (clinical and diagnostic) should be
present. In absence of a diagnostic aid, clinical
variable will suffice
PCAP – D
(Pneumonia-II, Pneumonia Very Severe)
Sample Orders:
 Please admit to ICU
 Secure consent
 TPR Q4
 NPO
 Take initial O2 sat at room air via pulse oximeter
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 IV: D5LR or D5IMB at full maintenance rate + 20%
 Meds:
 For 3mons – 5yo:
 Primary Therapy
 Chloramphenicol 100mg/kg/day IVTT Q6hrs
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD
( ) ANST
 For 5yo above:
 Primary Therapy
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 or OD
( ) ANST
 Supportive Therapy
 Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥
38°C
 Start O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP - D with Acute Gastroenteritis
Sample Orders:
 Please admit to ICU
 Secure consent
 TPR Q4
 NPO
 Take initial O2 sat at room air via pulse oximeter
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 Serum Na, K
 Stool exam
 Long Lead -II
 Blood C/S (to rule out sepsis)
 IVF: D5LR or D5IMB at full maintenance rate OR
hydration rate
 Meds:
 Primary Therapy
 Chloramphenicol 100mg/kg/D IVTT Q6 ±
 Ampicillin 100mg/kg/D IVTT Q6 ( ) ANST
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 or OD
( ) ANST
 Supportive Therapy
 Paracetamol 10mg /kg/d IVTT Q4 pm for temp ≥
38°C
 Start O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for persistent purging, cyanosis, progress of DOB,
seizure or any untoward events
NOTE:
 If LL-II has shown flattened T wave and/or other signs of
hypokalemia like abdominal distention, head lag,
hyporeflexia, irregular heart rate and hypoactive
bowel sounds are NOTEd;
 may start side drip (SD) D5LR 1liter + 40mEqs KCl to
run on full maintenance. This will give an
approximate of 2- 4 mEqs of KCl/kg/day.
 if the patient is still on hydration, subtract the SD
drop factor from the mainline drop factor.(e.g.: if the
mainline IV (hydration line) runs at 125ugtts/min for 6
hour, this particular IV line is reduced to 83ugtts/min
in 6 hours if SD (KCl line) is started at 42ugtts/min).
 For serum Potassium less than 2mmol/L, do KCl fast
correction (see page 119-120)
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP-D with
Hyper-reactive Airway Disease
Sample Orders:
 Please admit to ICU
 Secure consent
 TPR Q4
 NPO
 Take initial O2 sat at room air via pulse oximeter
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 IV: D5LR or D5IMB at full maintenance rate + 20%
 Meds:
 For 3mons – 5yo:
 Primary Therapy
 Chloramphenicol 100mg/kg/day IVTT Q6hrs
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD
( ) ANST
 For 5yo above:
 Primary Therapy
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 or OD ( )
ANST
 Supportive Therapy
 Paracetamol 10mg /kg/d IVTT Q4 pm for temp ≥
38°C
 Nebulize with 1 neb salbutamol + ipratropium 3
doses in 15 mins interval, then Q4hr (if needed to
increase frequency to Q2, do alternate
nebulization with 1 neb plain salbutamol
 May ADD: nebulization with 1 neb budosemide
Q12 (depending on evaluation)
 O2 inhalation via facemask at 6 LPM
 Chest physiotherapy every after nebulization
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events

NOTE:
 HRAD improving thru salbutamol nebulization is
suggestive of asthma, if not we may be dealing with
bronchiolitis especially for patients under 6months old
 for bronchiolitis adding racemic solution nebulization
may help. How to prepare diluted epinephrine as
alternative racemic solution:
 mix epinephrine of diluted epinephrine 0.30 cc with
sterile water of 3.70 cc, to come up with a 4 cc
solution
 use 2 cc of this solution for nebulization with
frequency dependent on the assessment
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP-D with suspected PTB
Basis: The child has manifested signs and symptoms of
PCAP-D plus positive history of exposure to TB patients
and is TB symptomatic. TB symptomatic is define as a
child with any three (3) or more of the following signs
and symptoms:
 History of cough ≥ 2 weeks
 Unexplained fever of ≥ 2 weeks
 Weight loss, loss of appetite, failure to gain weight
 Failure to respond to 2 weeks of appropriate
antibiotics for lower respiratory infection
 Failure to regain previous state of health after 2
weeks of a viral infection or exanthema
 Fatigue, reduced playfulness or lethargy

Sample Orders:
 Please admit to ICU
 Secure consent
 TPR Q4
 NPO
 Take initial O2 sat at room air via pulse oximeter
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 PPD or sputum examination
 IVF: D5LR or D5IMB at full maintenance or hydration
rate
 Meds:
 For 3mons – 5yo:
 Primary Therapy
 Chloramphenicol 100mg/kg/day IVTT Q6hrs
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD
( ) ANST
 For 5yo above
 Primary Therapy
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 or OD
( ) ANST
 Supportive Therapy
 Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥≥
38°C
 Once diagnosis of PTB is confirmed start Anti-TB
medication
 Rifampicin 10mg /kg/day OD PO OR NGT
 Isoniazid 10mg /kg/day OD PO OR NGT
 Pyrazinamide 15mg/kg/day OD PO OR NGT
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure, hemoptysis
or any untoward events

NOTEs
 Anti-TB drugs are continued for at least 6 months. Two
(2) months for Pyrazinamide and six (6) months for
Isoniazid and Rifampicin. Follow-up visits should be
advised accordingly.
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP-D with Malnutrition
Sample Orders:
 Please admit to ICU
 Secure consent
 TPR Q4
 NPO
 Take initial O2 sat at room air via pulse oximeter
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 IV: D5LR or D5IMB at full maintenance rate (may shift to
heplock once on DAT)
 Meds:
 For 3mons – 5yo:
 Primary Therapy
 Chloramphenicol 100mg/kg/day IVTT Q6hrs
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD
( ) ANST
 For 5yo above:
 Primary Therapy
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 or OD ( )
ANST
 Supportive Therapy
 Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥
38°C
 May ADD:
 Oxacillin 100mg/kg/day slow IVTT Q6
( ) ANST
 Gentamycin 5mg/kg/day slow IVTT OD
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, Seizure or any
untoward events

NOTE:
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP – C
(Pneumonia-I, Pneumonia Severe)
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 NPO
 Take initial O2 sat at room air via pulse oximeter
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 IV: D5LR or D5IMB at full maintenance rate + deficit%
 Meds:
 For (+) Hib Immunization:
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
 For (-) or incomplete Hib Immunization:
 Ampicillin 100mg/kg/day IVTT Q6 ( ) ANST
 Alternative Therapy
 Cefuroxime 100mg/kg/day IVTT Q8 ( ) ANST OR
 Ampicillin-Sulbactam 150mg/kg/day IVTT Q8
( ) ANST
 Supportive Therapy
 Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥
38°C
 Start O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
Tuberculosis in Children

Diagnosis of TB in Children
 The PPS consensus confirmed that a ―positive culture
with or without a positive smear for M. tuberculosis is
a gold standard for the diagnosis of TB. However, in
the absence of bacteriological evidence, a child is
presented to have active TB if three (3) or more of
the following criteria are present:
1. Exposure to adult TB
2. TB symptomatic (as previously mentioned)
3. Positive Purified Protein Derivative (PPD) testing
4. Chest X-ray suggestive of TB
5. Other diagnostic test (ODT) findings suggestive of
TB (eg. Histological)

PPD Reading and Interpretation


Reading and interpretation of PPD is done at 48 – 72
hours after intradermal administration of 0.1cc solution
of PPD. The test is considered POSITIVE with intubation
of:
 >5mm in the presence of any of the following:
 History of close contact with a known or suspected
case of TB
 Clinical findings suggestive of TB
 Chest X-ray suggestive of TB
 Immunocompromised condition
 >10mm in the absence of the above

Classification of Tb in children
 Pulmonary TB – formation of lesion mainly in the lungs
 Primary Tuberculosis
 Progressive Primary Tuberculosis
 Eg. miliary TB, TB pleural effusion
 Extra-pulmonary TB
 Mild extra-pulmonary disease
 Eg. Cervical adenitis
 Serious or complicated extra-pulmonary TB
 Eg. Pott’s disease, TB meningitis
Spectrum of TB
Criteria TB TB Infection TB Disease
Exposure
Exposure Yes Yes Yes
Signs &
None None Positive
Symptoms
Positive Positive
PPD Negative (but negative in (but negative in
many children)a many children)a
(maybe positive,
Chest
Negative Negative negative or
X-ray
unreliable)b
Sputum (maybe positive,
Negative Negative
Exam negative)c
Other
Negative (may be positive)d (maybe positive)d
Diagnostics
a may be false negative in many children due to several factors
b may be positive, showing hilar adenopathy and the Ghon complex;

variable findings
c may be negative due to paucibacillary nature in children and difficult of

specimen collection, as with culture studies


d may be positive in immune-based tests like IGRA (interferon gamma

release assay); not to be routinely done

Initial Empiric Management of TB in Children

I : TB Exposure
Age Regimen Remarks
3 months Isoniazid
Less (as intensive  Re-evaluation after 3 months
than 5 treatment, to be and revise treatment
years modified based on accordingly
follow-up PPD result)
 Immediate prophylaxis is
controversial for >5 years old,
but is recommended by some
experts especially for
≥5
3 months Isoniazid undernutrition and
years
immunocompromised state
 Re-evaluation and classification
of TB and revision of treatment
flee well
II : Latent TB Infection (LTBI)
Condition Regimen Remarks
PPD conversion within past 1-2
9 months Isoniazid
years, (-)CXR
PPD (+) not due to BCG, (-
9 months Isoniazid
)CXR, (-) previous treatment
PPD (+) with stable/healed
9 months Isoniazid
lesion, (-) previous treatment In the
PPD (-) with stable/healed presence of
lesion, (+) previous treatment, primary
at risk for reactivation due to 1 – 2 months Isoniazid Isoniazid
a. Measles, pertussis, etc. Isoniazid for the resistance,
b. Conditions/drugs inducing duration of give 6 month
immunosuppression immunosuppression Rifampicin
(IDDM. Leukemia, Chronic
dialysis)
HIV infection/ persons at risk for
infection but HIV status is 12 months Isoniazid
unknown

III : Active TB Disease


Condition Intensive Continuation
 New smear negative pulmonary TB
4 month HR
 Less sever forms of extra-pulmonary 2 months
OR
TB HRZ
6 months HE
 New smear positive pulmonary TB
 New' smear negative pulmonary TB
with extensive parenchymal 4 month HR
2 months
involvement OR
HRZE (S)
 Severe forms of extra-pulmonary TB 6 months HE
(other than TB meningitis)
2 months
 Severe concomitant HIV disease 4 month HR
HRZS
2 months 7 – 10 months
 TB Meningitis
HRZS HE
 Miliary TB 2 months
 Bone and joint TB HRZES
 Previously treated smear positive OR 5 months HRE
pulmonary TB; relapse treatment 1 month
after interruption, treatment failure HRZE
Refer to MDRTB treatment
 Chronic MDR- and XDR TB
center
NOTE
Corticosteroids are recommended as adjunct treatment in
patients with complicated forms of TB (e.g. TB
meningitis, endobronchial TB and pericarditis). The drug
most frequently used is Prednisone given 2mg/kg/day
for 4 weeks. For the most seriously ill children the dose
may be increased to 4mg/kg/day (maximum dose of
60mg/day). The dose of prednisone should be
gradually tapered over 1-2 weeks before finally being
discontinued.

Diagnosis and Management of TB in Children according to


Category
Cat TB Cases Intensive Continuation
 New smear (+)
 New smear (-) with extensive
parenchymal lesions on CXR 2 months
I 4 months HR
 Severe forms of extra-pulmonary HRZE
TB (other than TB meningitis)
 Severe concomitant HIV disease
2 months
Ia  TB meningitis 4 months HR
HRZS
2 months
 Relapse
HRZES
 Return after default (RAD) 5 months
II OR
 Treatment failure HRE
1 month
 Other
HRZE
 New smear (-), (ODT & other
than in category 1) 2 months
III 4 months HR
 Less severe forms of extra- HRZ
pulmonary TB
 Chronic (still smear positive after Refer to MDRTB treatment
IV
DOTS) and MDR-TB center
Pleurisy
Definition:
 Is an inflammation of the pleura and often
accompanied by an effusion. The most common
cause of pleural effusion in children is bacterial
pneumonia, followed by tuberculosis (in the
Philippines).

Types of Pleurisy:
 Dry/Plastic/Parapneumonic
 associated with acute bacterial infections (S. aureus,
S. pyogenes, S. pneumoniae) viral pulmonary
infection, TB, connective tissue diseases like
rheumatic fever
 limited to visceral pleura with small amount of yellow
serous fluids and adhesions between pleural
surfaces
 Serofibrinous/Serosaguinous
 associated to lung infection
 inflammatory condition of the abdomen or
mediastinum
 metastatic neoplasm
 fibrinous exudates on pleural space and an
exudative effusion of serous fluid in the pleural cavity
 Purulent/ Empyema
 pus in the pleural space
 associated with staphylococci, less frequent with
pneumococci and H. influenza

Three Stages of Purulent Pleurisy/Empyema


 Exudative
 Fibrinous exudate forms on the pleural spaces
 Fibrinopurulent
 When fibrinous septae from causing loculation of the
fluid, with thickening of the parietal pleura. It may
dissect through the pleura into the lung parenchyma
if not drained, producing bronchopleural fistula and
pyopneumothorax
 Organization
 There is fibroblast proliferation, and pockets of
loculated pus developing thick-walled abscess
cavities or the lung may collapse and become
surrounded by a thick, inelastic envelop

Clinical Manifestations:
 Fever
 Pain exaggerated by deep breathing, coughing and
straining/ Respiratory distress
 Friction rub
 Dullness on percussion
 Decrease breath sounds on affected area
 Decrease fremitus on affected

Criteria to differential Exudates from Transudates


Exudative Effusion
Transudative
Parameters Purulent Complicated
effusion Empyema
effusion empyema
Thin
Appearance Serous Turbid Thick pus
exudate
Mean WBC 1,000 5,300 25,500 55,000
PMB (%) 50 >90 >95 >95
Protein fluid /
<0.5 >0.5 >0.5 >0.5
serum ratio
LDH fluid /
<0.6 >0.6 >0.6 >0.6
serum ratio
LDH (IU/L) <200 >200 >200 >200
Glucose
>60 <60 <60 <40
(mg/dL)
7.35 –
pH 7.4 – 7.5 7.2 – 7.35 <7.2
7.45
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 NPO
 Labs:
 CBC, pit
 CXRAP/L
 Chest UTZ
 ABG
 Chest thoracentesis (maybe done thru UTZ-guided)
 Bottle 1: pH, Cell count, differential count, Glucose,
Total Protein, LDH (5-10ml EDTA)
 Bottle 2: AFB, gram stain, C/S
 Bottle 3: Cytology and cell block
 IV: D5LR at full maintenance rate + deficit (%)
 Meds:
 For 3mons – 5yo:
 Primary Therapy
 Chloramphenicol 100mg/kg/day IVTT Q6hrs
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD (
) ANST
 For 5yo above:
 Primary Therapy
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 or OD ( )
ANST
 Supportive Therapy
 Paracetamol 10mg/kg/dose IVTT Q4 pm for temp ≥
38°C
 IF S. aureus is suspected, ADD:
 Oxacillin 100 mg/kg/day slow IVTT Q6 ( ) ANST OR
 Clindamycin 20-40 mg/kg/day IVTT Q6-8
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Refer to Surgery for evaluation and co-management
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events

Indication for Chest Tube Insertion:


 gross pus thoracentesis
 presence of organism on gram stain of the pleural
effusion
 pleural fluid glucose of <50mg/L
 pleural pH below 7.00 and 0.15 units lower than arterial
pH

NOTE:
 If thoracentesis is done, the fluid aspirated should be
replaced with (same amount) PNSS thru IV push.
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
Consolidation
(Lobar Pneumonia)
Definition:
 Lobar pneumonia is an acute exudative
inflammation of an entire pulmonary lobe,
produced in 95% of cases by S. pneumonia.
 Consolidation is a pathologic disease process that
takes place with certain types of lung infections. It is
a solidification of fluids from pulmonary edema,
inflammatory exudates, pus, inhaled water, or blood
into a firm and dense mass.

Manifestations:
 Fever
 Cough
 Expansion of the thorax on inspiration is reduced on the
affected side
 Vocal fremitus is increased on the side with
consolidation
 Percussion is dull in affected area
 Inspiratory crackles
 Vocal resonance is increased
 Pleural rub may be present
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 IV: D5LR or D5IMB at full maintenance rate + deficit (%)
 Meds:
 Primary Therapy
 Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST ±
 Gentamycin 5mg/kg/day IVTT OD OR
 Amikacin 10-15mg/kg/day IVTT OD
 Alternative Therapy
 Ceftriaxone 100mg/kg/day IVTT Q12 OR OD ( )
ANST OR
 Cefotaxime 100mg/kg/day IVTT Q6 OR q12 ( ) ANST
OR
 Chloramphenicol 100mg/kg/day IVTT Q6 AND
 Gentamycin 5mg/kg/day IVTT OD OR
 Amikacin 10-15mg/kg/day IVTT OD
 Supportive Therapy
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥ 38°C
 O2 inhalation via facemask at 6 LPM
 Do chest physiotherapy as frequent as possible
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
 Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 Once with improvement within 72 hours;
 shift O2 to nasal or discontinue
 start feeding
 shift medication to oral preparation
 Chloramphenicol IV to Chloramphenicol oral
 Paracetamol IV to paracetamol oral
 Penicillin IV to Amoxicillin OR Co-amoxiclav oral
 Ceftriaxone IV to Co-amoxicillin or Cefixime oral
 Consider sending the patient home
 Advice proper hygiene and good nutrition
 If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
 If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
Nosocomial Pneumonia
Definition:
 Nosocomial pneumonia refers to any pulmonary
infection; retracted by a patient in a hospital at least
48 – 72 hours after being admitted.
 usually caused by bacteria, rather than a virus. It
lengthens a hospital stay by 1— 2 weeks.

Etiology:
 Bacteria:
 Gram negative bacilli (52%)
 Staphylococcus aureus (19%)
 Enterobacter spp (18.1%)
 Pseudomonas aeruginosa (17.4%)
 Hemophilus spp. (5%)
 Klebsiella pneumomiae

Manifestation:
 Recurrence of fever after being afebrile
 Recurrence of tachypnea and/or respiratory distress
 Cough
 Chills
 Shortness of breath
 Loss of appetite
 May have Nausea and vomiting
 Crackles or decreased breath sounds
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 Blood C/S
 IV: D5 LR or D5IMB at full maintenance rate + deficit (%)
 Meds:
 Primary Therapy
 Ceftazidime 100mg/kg/day IVTT Q6 ( ) ANST PLUS
 Amikacin 15mg/kg/day IVTT OD
 Alternative Therapy
 Cefipime 100mg/kg/day IVTT Q12 OR OD ( ) ANST
OR
 Piperacillin + Tazobactam 150mg/kg/day IVTT Q6
( ) ANST OR
 Meropenem 60mg/kg/day (max = 120mg/kg/day)
IVTT Q8 PLUS
 Amikacin 10-15mg/kg/day IVTT OD
 IF MRSA is highly suspected, ADD
 Vancomycin 40-60mg/kg/day to run as drip for 1
hour Q6
 Supportive Therapy
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥ 38°C
 O2 inhalation either nasal cannula at 3 LPM OR
facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTEs
 The antibiotic treatment ranges from 7 to 10 days
 If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
 If with no improvement after 72 hours, consider referral
to tertiary hospital or to specialists.
 If patient goes on HAMA, we don’t have any choice
but to shift to oral medication that can cover the
causative microorganisms either by growth or
incidence (like Chloramphenicol, Ciprofloxacin,
Levofloxacin, Moxifloxacin). It is the attending
physician’s call to choose the best management for
the patient.
Laryngotracheobronchitis

 Also called viral croup


 Acute inflammatory disease of the larynx (within the
subglottic space)
 most common etiology is parainfluenza virus
 SSx: rhinorrhea, pharyngitis, and low-grade fever 1-3
days before signs of UAO, inspiratory stridor, hoarse
voice, barking cough
 neck x-ray: subglottic narrowing - ―steeple sign‖ (X ray
findings do not correlate well with disease severity)
Westley croup score:
Bronchial Asthma

Definition:
 Asthma is a chronic inflammatory disorder of the
airways resulting in episodic airway obstruction.
 Chronicallt, inflamed airways are hyperresponsive,
they become obstructed and airflow is limited (by
bronchoconstriction, mucus plugs and increased
inflammation) when airways are exposed to various
risk factors.
Common Risk Factors in children include exposure to:
 Allergens
 House dust mites
 Animals (dogs, cats)
 Cockroaches
 Molds
 Tobacco smoke
 Biomass fuels
 Respiratory (viral) infection
 Emotional stress
 Some drugs (NSAIDs, Aspirin, β-blockers)

Criteria for Making the Diagnosis of Asthma


 History of variable respiratory symptoms
Consider Asthma if any of the following signs or
symptoms are present
 Frequent episode of wheezing (with or without
shortness of breath, cough, chest tightness) – more
than once a month
 Activity-induced cough or wheeze
 Cough particularly at night during periods without
viral infection
 Absence of seasonal variation in wheeze
 Symptoms that persist after age 3 years
 Symptoms occur or worsen in the presence of
 Aeroallergens (house dust mites, cockroach,
molds/fungi, companion animals/pets)
 Exercise/laughter
 Pollen
 Respiratory (viral) infection
 Strong emotional expression
 Tobacco smoke
 Symptoms improve when asthma medication is
given
 Evidence of variable expiratory air (Adults and children
beyond 5 years)
 Using spirometer or peak flow meter

Physical Findings
 Tachypnea
 Dyspnea with prolonged expiratory
 Wheezing (maybe absent in severe spasms)
 Prominent accessory respiratory muscles
involvement (nasal flare, intercostals/subcostal
retractions)
 Cyanosis
 Tachycardia
 Hyperinflation of the chest
 Pulsus paradoxus

NOTE
 Not all young children who wheeze have Asthma, the
younger the child, the greater the likelihood that an
alternative diagnosis my explain recurrent wheeze

Diagnosis
 There are three ways to diagnose asthma, it can be
through:
 Classification of Asthma based on severity
 Level of Asthma symptom control
 Severity of Asthma Exacerbation
The diagnosis of asthma using the classification based
on severity is usually used for patient who comes in for
consult for the FIRST TIME and without any
exacerbation or attack at the time of consult. This
diagnosis serves as an initial approach to
management (see Stepwise Approach for Managing
Asthma in Children)

Classification of Asthma based on Severity


Parameter Classification
Persistent
Intermittent
Mild Moderate Severe
<1 Daily;
Daily;
Day x/week Affects
< 1 x/week Limits daily
symptoms but less daily
activities
than daily activities
Night ≤2 >2 >1 >1
symptoms x/month x/month x/month x/month
≥ 80% ≥ 80%
PEFR 60 – 79% < 60%
predicted predicted
PEFR
< 20% 20 – 30% > 30% > 30%
Variablity
≥ 80% ≥ 80%
FEV1 60 – 79% < 60%
predicted predicted
However, for patients doing FOLLOW-UP check up (usually after a month upto 3) the
diagnosis shifts based on the ―level of asthma symptom control‖. This new diagnosis
dictates whether to do ―step-up or stem-down‖ management for the succeeding
months (see Stepwise Approach for Managing Asthma in Children)

Level of Asthma Symptom Control


Characteristics
Well Controlled Partly Controlled Uncontrolled
(Questions/Answers)
Daytime symptoms more than [ ] Yes
2x a week? [ ] No
Any night waking due to [ ] Yes
Asthma? [ ] No
Reliever needed more than 2 [ ] Yes
days a week? [ ] No None of these 1 – 2 of these 3 – 4 of these
Any activity limitation due to [ ] Yes
asthma? [ ] No
Above 5 years: is the lung
[ ] Yes
function (PEF or FEV1) below
[ ] No
80% predicted or personal best?
In the event, a patient comes in for consult in asthmatic attack or exacerbations,
whether it is his first time to come for consult or not, the diagnosis using severity of
asthma exacerbation is usually needed. This is the usual diagnosis used in patients who
need admission and immediate intervention
Severity of Asthma Exacerbation
Respi Arrest
Parameter Mild Moderate Severe
Imminent
Talking
Infant – softer, At rest infant
Walking
shorter cry, stops feeding
Breathless Imminent
difficult feeding
Hunched
Can lie down Prefer sitting
forward
Talks in Sentences Phrases Words
Usually
Alertness May be agitated Usually agitated Drowsy or confused
agitated
Respiratory Rate Increased Increased Increased Bradypnea
Normal Respiratory Age Normal Rate
rate of awake children <2 months <60/min
2 – 12 months <50/min
1 – 5 years <40/min
6 – 8 years <30/min
Accessory muscles Thoraco-abdominal
Usually NOT Usually Usually
& retractions movement
Moderate, often
Wheeze only and Load Usually load Absence of wheeze
expiratory
Pulse/min < 100/min 100 – 120/min > 120/min Bradycardia
Guides to limits of normal Age Normal Rate
pulse rate in children
Infant 2 – 12 months <160/min
Preschool 1 – 5 years <120/min
School age 6 – 8 years <110/min
Absence suggests
Absent May be present Often Present
Pulsus Paradoxus respiratory muscle
<10 mmHg 10 – 25 mmHg 20 – 40 mmHg
fatigue
PEF after initial
Over 80% Approx. 60 – 80% <60%
bronchodilator
Normal <60 mmHg
PaO2 (on air) Test not usually >60 mmHg Possible
necessary cyanosis
>45 mmHg
And/or PaCO2 < 45 mmHg <45 mmHg Possible respi
failure
SaO2 >95% 91.95% <90%
Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents
NOTE: the presence of several parameters, but not necessarily all, includes the general classification of
the exacerbation
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 NPO
 O2 inhalation via facemask at 6 LPM
 Labs:
 CBC, plt
 CXR AP/L
 ABG
 IV: D5LR or D5 IMB at full maintenance rate + deficit (%)
 Meds:
 Nebulize with 1 neb salbutamol + ipratropium 3
doses in 15 mins interval, then Q4 (if needed to
increase frequency to Q2, do alternate nebulization
with 1 neb plain salbutamol)
 May ADD: nebulization with 1 neb budesonide Q12
(depending on the evaluation)
 Hydrocortisone 8mg/kg IVTT as loading dose; then
maintain at 4mg/kg/d IVTT(frequency depends on
the evaluation Q4; Q6; Q12) OR
 Methylprednisolone 2mg/kg IVTT/IM, then
2mg/kg/day Q6 hour
 Paracetamol 10mg/kg/d IVTT Q4 PRN for temp ≥
38°C
 If with concomitant Pneumonia:
 For 3mons- 5yo:
 Chloramphenicol 100mg/kg/D IVTT Q6
 For 5yo above :
 Penicillin Na 100,000 IU/kg/D slow IVTT OR as drip
Q6 ( ) ANST
 Chest physiotherapy every after nebulization
 Place patient on moderate high back rest
 Monitor v/s Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
 If air movement is still poor despite maximizing above
therapy, you may consider giving the following:
 Subcutaneous or intramuscular route: though many
experts don’t advice these
 Terbutaline 0.01cc/kg SQ, then repeat after 15mins
upto 2 doses OR
 Epinephrine 0.01cc/kg SQ/IM (1:1,000; max dose
0.5mL) every 15mins upto 3 doses
 Drips
 Magnesium sulfate 25-75mg/kg/dose IV infused
over 20 mins every 4-6hours upto 3-4 doses
 Terbutaline 2-10mcg/kg IV load, followed by
continuous infusion at 0.1-1.0mcg/kg/min titrated t
effect the appropriate cardiac monitoring in ICU
set up
 Intubation

NOTE
 Once with improvement within 24 hours:
 Shift O2 to nasal or discontinue
 Start feeding
 May shift medication to oral preparation (if
indicated)
 Consider sending the patient home
 Advice home management according to the
diagnosis based on severity or level of control as
shown in succeeding tables
Stepwise Approach for Managing Asthma in Children
Intermittent Asthma Persistent Asthma: Daily Medications

STEP DOWN: if possible (and Asthma is well controlled at STEP UP: if needed (first check inhale technique, adherence,
Age Therapy least 3 months) environmental control, and comorbid condition)

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6


Preferred SABA PRN Lose-dose ICS Medium-dose ICS Medium-dose ICS High-dose ICS + High-dose ICS +
+ Either LABA or LTRA Either LABA or LTRA
0–4 Either LABA or and oral
year LTRA corticosteroids
Alternative Cromolyn or
Montelukast
Preferred SABA PRN Lose-dose ICS Either Low-dose ICS Medium-dose ICS High-dose ICS + High-dose ICS +
± LABA, LTRA or + LABA LABA
theophylline or LABA and oral
Medium-dose ICS corticosteroids
5–
Alternative Cromolyn or Medium-dose ICS High-dose ICS + High-dose ICS +
11
Montelukast + either either LABA
year
LTRA or LTRA or theophylline + oral corticosteroids
theophylline and consider
omalizumab for
patients with allergies
Preferred SABA PRN Lose-dose ICS Low-dose ICS + Medium-dose ICS High-dose ICS + High-dose ICS +
either LTRA or + LABA and consider LABA
Medium-dose ICS LABA omalizumab for and oral
patients with corticosteroids and
allergies consider omalizumab
≥ 12 for patients with
year allergies
Alternative Cromolyn, LTRA, Low-dose ICS + Medium-dose ICS +
nedocromil, or LTRA, theophylline LTRA, theophylline
theophyline
Each step: Patient education, environment control, and management of comorbidities.
Age ≥ 5 yr: Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
QUICK-RELIEF MEDICATION FOR ALL PATIENTS
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatment at 20-min intervals as needed
Short course of oral systemic corticosteroids may be needed
Caution: Use of SABA >2 days/week for symptoms relief (not prevention of exercise-induced bronchospasm) generally indicates
inadequate control and the need to step up treatment
For ages 0-4 yr: With viral respiratory infection: SABA q4-6 up to 24 hr (longer with physician consult). Consider short course of systemic
corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations.
NOTE:
 The stepwise approach is meant to assist, not replace, the clinical decision-making required to meet individual patients needs
 If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up
 If clear benefit is not observed within 4-6wk, and patient family medication technique and adherence are satisfactory, consider
adjusting therapy or alternative diagnosis
 Studies on children aged 0-4yr are limited. The stepwise approach is meant to assist, not replace, the clinical decision-making
required to meet individual patient needs
 Clinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and treat anaphylaxis
that may occur
 Theophylline is a less desirable alternative due to the need to monitor serum concentration level
Allergology
Doctors’ Guide
Anaphylaxis

The World Allergy Organization defines anaphylaxis as a


severe, life-threatening, generalized or systemic
hypersensitivity reaction. Allergic anaphylaxis is termed if
reaction is mediated by immunologic mechanism (eg. IgE,
IgG, & immune-complex-complement related) and
anaphylaxis from non-immunologic reaction is called Non-
allergic anaphylaxis (anaphylactoid). Most anaphylactic
reactions begin within 30 mins of exposure to the allergen,
especially if by injection while others may take hours. Signs
and symptoms usually resolve within a few hours in surviving
patients

Clinical Criteria for Diagnosis


Anaphylaxis is highly likely when any one of the following three criteria is fulfilled
1. Sudden onset of an illness AT LEAST ONE OF THE FOLLOWING
(minutes to several hours),
with involvement of the A. Sudden respiratory symptoms and signs (eg. Shortness of
skin, mucosal tissues, or breath, wheeze, cough, stridor, hypoxemia)
both (eg. Generalized B. Sudden reduced BP or symptoms of end-organ
hiver, itching, swollen lips- dysfunction (eg. Hypotonia, collapse, incontinence)
tongue-uvula)
OR A. Sudden skin or mucosal symptoms or signs (eg.
2. Two or more of the Generalized hives, itch-flush, swollen lips-tongue-uvula)
following that occur B. Sudden respiratory symptoms and signs (eg. Shortness of
suddenly after exposure breath, wheeze, cough, stridor, hypoxemia)
to a LIKELY allergen or C. Sudden reduced BP or symptoms of end-organ
other trigger* for that dysfunction (eg. Hypotonia, collapse, incontinence)
patient (minutes to D. Sudden gastrointestinal symptoms (eg. Crampy
several hours) abdominal pain, vomiting)
OR
Reduced blood pressure (BP) after exposure to a KNOWN allergen** for that patients (minutes
to several hours):
Infant & children: low systolic BP (age-specific Adult: systolic BP of less than 90mmHg or
or greater than 30% decrease in systolic BP*** greater than 30% decreases from the
person’s baseline
* For example, immunologic but IgE-independent, or non-immunologic (direct mast cell
activation)
** For example, after an insect sting, reduced BP might be the only manifestation of
anaphylaxis, or, after allergen immunotherapy, generalized hives might be the only initial
manifestation of anaphylaxis
*** Low systolic BP for children is defined:
Less than 70mmHg 1 month to 1 year
Less than (70mmHg + [2 x age]) 1 to 10 years
Less than 90mmHg 11 to 17 years
Normal heart rate ranges from:
80 – 140 bpm 1 – 2 year
80 – 120 bpm 3 years
70 – 115 bpm > 3 years
Summary of Initial Treatment of Anaphylaxis
1. Have a written emergency protocol for recognition
of anaphylaxis and rehearse it regularly
2. Remove exposure to the trigger if possible. Eg.
Discontinuation of an intravenous diagnostic or
therapeutic agent that seems to be triggering
symptoms
3. Assess the patient’s circulation, airway, breathing,
mental status, skin, and body weight (mass)
Promptly and simultaneously, perform STEPS 4, 5, & 6
4. Call for help: resuscitation tem (hospital) or
emergency medical services (community) if
available
5. Inject epinephrine (adrenalin) intramuscular in the
mid-anterolateral aspect of the thigh, 0.01 mg/kg
of 1:1,000 (1mg/ml) solution, maximum of 0.5 mg
(adult) or 0.3 mg (child). Record the time of the
dose and repeat it in 3-5minutes, if needed. Most
patients respond to 1-2doses
6. Place patient on the back or in a position of
comfort if there is respiratory distress and/or
vomiting; elevate the lower extremities; fatality can
occur within seconds if patient stands or sits
suddenly
7. When indicated, give high-flow supplemental
oxygen (6-8LPM) by face mask or oropharyngeal
airway
8. Establish IV access using needles or catheters with
wide-bore cannulae (14-16 gauge). When
indicated, give 1-2 liters of 0.9% (isotonic) saline
rapidly (eg. 5-10 mL/kg in the first 5-10mins to an
adult; 10 mL/kg to a child)
9. When indicated at any time, perform
cardiopulmonary resuscitation with continuous
chest compression and rescue breathing
10. In addition: At frequent, regular intervals, monitor
patient’s Blood pressure, heart rate and function,
respiratory status, and oxygenation (monitor
continuously, if possible
Sample Orders:
 Please admit to Medical/ICU ward
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, plt
 Serum Na, K, AST, ALT, ESR
 CXR APL (optional)
 IV: Plain LR 1L to run as maintenance rate
 when indicated run in 5 to 10 minutes:
 10cc/kg to a child
 20cc/kg to a bigger patient
 5 – 10cc/kg to an adult weight
 Meds:
 Epinephrine 0.01 cc/kg IM, antero-lateral aspect of
the thigh (may give every 5 – 15 mins interval if with
no improvement but most patient respond to 1 – 2
doses)
 Hydrocortisone 4mg/kg/dose IVTT q8hr
 Ranitidine 2-4mg/kg/day IVTT q8hr
 Diphenhydramine 1mg/kg/dose IVTT q6-8hr
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥38°C
 Nebulize with 1 neb salbutamol + ipratropium 3
doses in 15 mins interval, then Q4 (if needed to
increase frequency to Q2, do alternate nebulization
with 1 neb plain salbutamol)
 May ADD: nebulization with 2cc neb racemic
solution (depending on the evaluation)
 Elevate the lower extremities and avoid standing up or
sitting (to prevent empty vena-cava syndrome)
 O2 inhalation via facemask at 6L/min
 Place the patient on supine position for 4-6hours
 Watch out for biphasic reaction within 4-6hours after
the first anaphylactic reaction
 Monitor V/S Qhourly (BP, RR, HR, Oxygenation) for one
shift then mat reduce to Q2-4hourly
 I & O Q shift and record quantitatively

NOTE:
 Dopamine drip maybe considered for hypotension
 Consider intubation for angioedema of the epiglottis
and laryngospasm, and stridor and excessive use of
accessory muscles for respiration.
Gastroenterology
Doctors’ Guide
Diarrheal Diseases
Definition:
 passage of unusually loose or watery stools, usually
at least three times in a 24 hour period.
 It is the consistency of the stools rather than the
number that is most important (WHO 2004).
 The pathogenesis of most episodes of diarrhea can
be explained by secretory, osmotic, or motility
abnormalities or a combination of those.
Ecology:
 It can be divided into 6 ―Is‖ namely Infection,
Inflammation, Infestation, Indigestion, In-absorption
(appropriate term is Malabsorption), and Idiopathic.

Mode of transmission:
 Infectious agents that cause diarrheal disease are
usually spread by the fecal-oral route, specifically by:
 ingestion of contaminated food or water
 contact with contaminated hands
 Host factors associated with increase susceptibility to
diarrheal diseases
 Malnutrition
 Immunodeficiency or immunologic suppression
 Reduced gastric acidity
 Decrease intestinal motility
 Effective Preventive Intervention:
 breastfeeding
 improved practices
 use of clean water
 practice of good hygiene (like proper handwashing)
 measles immunization
 proper and good food handling
Child with diarrhea**
A B C
Lethargic,
Condition Well, alert Restless, irritable
unconscious
Eyes Normal Sunken Very sunken/dry
Tears Present Absent Absent
Moist Dry Very dry
Mouth /
Drinks normally, Thirsty, drinks Drinks poorly or
Tongue
not thirsty eagerly not able to drink
Goes back Goes back Goes back very
Skin Pinch
quickly slowly slowly
Weight
< 5% 5 – 10% >10%
loss
Fluid
≤ 50 mg/kg 50 – 100 mg/kg > 100 mg/kg
deficit
▼ ▼ ▼
If the patient If the patient
has 2 or more has 2 or more
NO SIGNS OF signs in B, the signs in C, the
DEHYDRATION patient has patient has
SOME SEVERE
DEHYDRATION DEHYDRATION
▼ ▼ ▼
Treatment Treatment Treatment
Plan A Plan B Plan C

NOTE:
 Only 2 parameters needed in category
 Ask for presence of blood in the stools. If present, treat
with appropriate antibiotics for shigella or amoebiasis.
Treatment Plan A

4 Rules of Home Treatment


 Give extra fluid (as much as the child will take)
 Breastfeed frequently & longer at each feeding
 if the child is exclusively breastfed, give one or more
of the following in addition to breastmilk
 ORS solution
 Food based fluid (e.g. soup, rice, water)

The general rule is to give as much fluid as the child


wants until diarrhea stops. After each loose stool, give:
 Children <2 years old
 50 – 100 mL
 Children 2-10 years old
 100 – 200 mL
 Older children and adults
 as much as they want

 Give frequent small sips from a cup


 If the child vomits, wait for 10 min then resume
 Continue giving extra fluids until diarrhea stops
 Give Zinc supplements
 < 1yo: 10mg/ml drop, 1mL OD PO x 2 weeks
 > 1yo: 20mg/5ml syrup, 5mL OD PO x 2 weeks
 Continue feeding
 Know when to return
Treatment Plan B

 Give 75 cc/kg ORS solution over a 4-hour period. If the


patient wants more ORS, give more.
 Encourage the mother to continue breastfeeding.
 Infants below 6 months who are not breastfed should
be given 100-200 mL clean water during this period.
 During the initial stages of therapy, while still
dehydration, children may consume up to 20 cc/kg
per hour if necessary.
 If the child vomits, wait for 10 min then resume
After 4 hours
 Reassess the child & classify dehydration status
 Select the appropriate plan to continue treatment
 Begin feeding the child while at the clinic
 After rehydration advise mother on when to return
immediately
 Follow-up in 5 days if not improving
Treatment Plan C

 Start IV fluids immediately; give 100cc/kg plain LR (or


normal saline if not available) as follows:
 Infants < 12months
 First give 30cc/kg in 1 hour
 Then give 75cc/kg in 5 hours
 Older
 First give 30cc/kg in 5 hour
 Then give 75cc/kg in 2.5 hours
 Reassess the patient every hour.
 If hydration is not improving, give IV drip more rapidly.
 After 6 hours (infants) or 3 hours (older patients),
evaluate the patient again then choose the
appropriate treatment plan (A, B, or C) to continue
treatment.

 *Repeat this phase once the radial pulse is still very


weak or not detectable.
Oresol
Glucolyte 60
For acute DHN secondary to GE or other forms of
diarrhea except CHOLERA. In burns, post-surgery
replacement or maintenance, mild-salt loosing
syndrome, heat cramps and heat exhaustion in adult

Glucose 100 mmol/L Mg 5 mmol/L


Na 60 mmol/L Citrate 10 mmol/L
K 20 mmol/L Gluconate 5 mmol/L
Cl 50 mmol/L

Hydrite
2 tab in 200ml water or 10sachets in 1L water

Glucose 111 mmol/L HCO3 5 mmol/L


Na 90 mmol/L Glucose 11 mmol/L
K 20 mmol/L
Cl 80 mmol/L

Pedialyte 45 0r 90
Prevention of DHN & to maintain normal fluid
electrolyte balance in mild to moderate dehydration

Glucose 45 mEq Glucose 90 mEq


Na 20 mEq Na 20 mEq
K 35 mEq K 80 mEq
Citrate 30 mEq Citrate 30 mEq
Dextrose 20 g Dextrose 25 g

Pedialyte mild 30
To supplement fluid & electrolyte loss due to active
play, prolonged exposure, hot and humid environment

Glucose 30 mEq Mg 4 mEq


Na 20 mEq Lactate 20 mEq
K 30 mEq Ca 4 mEq
Energy 20 kcal/100 ml
AGE with Hypovolemic Shock
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 NPO temporarily
 Labs:
 CBC, plt
 Stool Exam, Stool Culture (for Cholera suspect)
 LL-II
 Push 20cc/kg PNSS IV bolus (may repeat upto 3x if still
with no/fair pulses)
 IV: D5LR 1L or Plain LR 1L to run at:
 < 1 year old
 30cc/kg in 1 hour, then regulate to 70cc/kg in 5
hours
 > 1 year old
 30cc/kg in 30 mins, then regulate to 70cc/kg in 2.5
hours
 (For malnourished children, compute IV as AGE with
some DHN, because it’s impossible to distinguish
reliably between some dehydration and severe
dehydration.)
 Refer for reassessment due at (write the specific time)
 Meds:
 Antibiotics depends on the etiology (see Antibiotics
used to treat Specific cause of diarrhea)
 Vitamin A & Zinc sulfate (according to age, see
Adjunct management for diarrhea)
 Paracetamol 10mg/kg/dose IVTT OR PO Q4 PRN for
temp ≥ 38°C
 I & O Q shift and record quantitatively
 Please push 10 cc/kg PNSS every after purging
 Monitor V/S & IV flow Qhourly
 Refer for change of sensorium, poor pulses, seizure
 Monitor vomiting, LBM
NOTE:
 If LL-II has shown flattened T wave and/or other signs of
hypokalemia like abdominal distention, head lag,
hyporeflexia, irregular heart rate and hypoactive
bowel sounds are NOTEd:
 may start side drip (SD) D5LR 1 liter + 40 mEqs KCl to
run on full maintenance. This will give an
approximate of 2- 4 mEqs of KCl/kg/day.
 if the patient is still on hydration, subtract the SD
drop factor from the mainline drop factor,(eg: if the
mainline IV (hydration line) runs at 125 ugtts/min for 6
hour, this particular IV line is reduced to 83 ugtts/min
in 6 hours if SD (KCl line) is started at 42 ugtts/min).
 For serum Potassium less than 2 mmol/L, do KCl fast
correction (see page 119-120)
 Dopamine may be started in separate line if maximum
of 60cc/kg of PNSS is administered (or equivalent to 3
pushed of 20cc/kg)
AGE with Severe Dehydration
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 Small frequent feeding (ORS 10cc/kg every after
purging)
 Labs:
 CBC, plt
 Stool Exam, Stool Culture (for Cholera suspect)
 Serum Na, K
 LL-II
 IV: D5LR 1L or Plain LR 1L to run at:
 < 1 year old
 30cc/kg in 1 hour, then regulate to 70cc/kg in 5
hours
 > 1 year old
 30cc/kg in 30 mins, then regulate to 70cc/kg in 2.5
hours
 (For malnourished children, compute IV as AGE with
some DHN, because it’s impossible to distinguish
reliably between some dehydration and severe
dehydration.)
 Refer for reassessment due at (write the specific time)
 Meds:
 Antibiotics depends on the etiology (see Antibiotics
used to treat Specific cause of diarrhea)
 Vitamin A & Zinc sulfate (according to age, see
Adjunct management for diarrhea)
 Paracetamol 10mg/kg/dose IVTT OR PO Q4 PRN for
temp ≥ 38°C
 I & O Q shift and record quantitatively
 Monitor V/S & IV flow Qhourly
 Refer for change of sensorium, DOB, poor pulses,
 Monitor vomiting, LBM (time, frequency, character and
amount)
NOTE:
 If LL-II has shown flattened T wave and/or other signs of
hypokalemia like abdominal distention, head lag,
hyporeflexia, irregular heart rate and hypoactive
bowel sounds are NOTEd:
 may start side drip (SD) D5LR 1 liter + 40 mEqs KCl to
run on full maintenance. This will give an
approximate of 2- 4 mEqs of KCl/kg/day.
 if the patient is still on hydration, subtract the SD
drop factor from the mainline drop factor,(eg: if the
mainline IV (hydration line) runs at 125 ugtts/min for 6
hour, this particular IV line is reduced to 83 ugtts/min
in 6 hours if SD (KCl line) is started at 42 ugtts/min).
 For serum Potassium less than 2 mmol/L, do KCl fast
correction (see page 119-120)
AGE with Some/Mild Dehydration
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 Small frequent feeding (ORS 10cc/kg every after
purging)
 Labs:
 CBC, plt
 Stool Exam, Stool Culture (for Cholera suspect)
 Serum Na, K
 LL-II
 IV: D5LR 1L or Plain LR 1L to run at:
 Well nourished
 75 cc/kg in 6 hour, then refer for reassessment due
at (write the specific time)
 Malnourished
 75 – 100 cc/kg in 12 hours, then refer for
reassessment due at (write the specific time)
 Meds:
 Antibiotics depends on the etiology (see Antibiotics
used to treat Specific cause of diarrhea)
 Vitamin A & Zinc sulfate (according to age, see
Adjunct management for diarrhea)
 Paracetamol 10mg/kg/dose IVTT OR PO Q4 PRN for
temp ≥ 38°C
 I & O Q shift and record quantitatively
 Monitor V/S & IV flow Qhourly
 Monitor vomiting, LBM (time, frequency, character and
amount)
NOTE:
 If LL-II has shown flattened T wave and/or other signs of
hypokalemia like abdominal distention, head lag,
hyporeflexia, irregular heart rate and hypoactive
bowel sounds are NOTEd:
 may start side drip (SD) D5LR 1 liter + 40 mEqs KCl to
run on full maintenance. This will give an
approximate of 2- 4 mEqs of KCl/kg/day.
 if the patient is still on hydration, subtract the SD
drop factor from the mainline drop factor,(eg: if the
mainline IV (hydration line) runs at 125 ugtts/min for 6
hour, this particular IV line is reduced to 83 ugtts/min
in 6 hours if SD (KCl line) is started at 42 ugtts/min).
 For serum Potassium less than 2 mmol/L, do KCl fast
correction (see page 119-120)
Antibiotics used to treat Specific cause of diarrhea

Cholera:
 Tetracycline 12.5 mg/kg/day PO Q6 x 3 days (for > 8
yo); OR
 Erythromycin 12.5 mg/kg/day PO Q6 x 3 days; OR
 Cotrimoxazole 8mg/kg/day PO Q12 x 7 days (based
on Trimethoprim)

Shigella Dysentery:
 Ciprofloxacin 15 mg/kg/day PO Q12 x 3 days
 Ceftriaxone 100 mg/kg/day IVTT OD; Q12 x 2-5 days
( ) ANST

Amoebiasis & Giardiasis:


 Metronidazole 30-50 mg/kg/day PO Q8 x 5 days (10
days for severe disease)

Parasitism:
 Mebendazole 100 mg PO BID for 3days or 500mg single
dose
 Albendazole 400 mg PO single dose

 Pyrantel pamoate 11 mg/kg PO single dose (max 1gm)


OR
 Oxantel-pyrantel 15-20 mg/kg PO single dose OR
 Piperazine citrate 75 mg/kg/day x 3 days, PO
Adjunct management for diarrhea
 Zinc Sulfate:
 < 1yo: 10mg/ml drop, 1mL OD PO x 2 weeks
 > 1yo: 20mg/5ml syrup, 5mL OD PO x 2 weeks
 Vitamin A
 0 – 6 months : 50,000 U PO
 6 – 12 months: 100,000 U PO
 > 12 months: 200,000 U PO
 Erceflora neb:
 < 6 months: ½ neb BID PO x 3-5 days
 > 6 months: 1 neb BID PO x 3-5 days
 Hidrasec sachet:
 1.5 mg/kg/dose PO 3x a day until cessation of
diarrhea
Infectious
Doctors’ Guide
Dengue Hemorrhagic Fever (DHF)
Definition:
 most important arthropod-borne viral diseases today
in terms of morbidity and mortality.
 transmitted through a bite of mosquito vector Aedes
aegypti.
 Caused by single stranded RNA virus belonging to
genus Flavivirus.
 Dengue viruses type 1, 2, 3 and 4
 One type can produce lifelong immunity against
that specific serotype with short-term cross
protection against the other 3 types which is usually
6 months
Incubation period:
 Usually 4 to 6 days (minimum of 3 days, maximum of
10days)
Clinical Manifestation:
1997 WHO Grading of Severity 2009 WHO PHIC Dengue
Dengue Case Classification
Classification
Grade I
 Fever (2-7 days); non-
Dengue without
specific constitutional
warning signs
symptoms, positive
Dengue I
tourniquet test
Grade II
Dengue with
 Grade I plus spontaneous
warning signs
bleeding
Grade III
 Grade II plus circulatory
failure: rapid and weak
pulse, narrow pulse
pressure, hypotension, cold,
clammy skin, restlessness
Severe dengue Dengue II
(compensated shock)
Grade IV
 Grade III plus profound
shock with undetectable BP
and pulse (hypotensive
shock)

Complications:
 Central Nervous System (Dengue Encephalopathy)
 Convulsion,
 Change in consciousness,
 spasticity/hyporeflexia,
 CSF-normal
 Cardiac Involvement
 Renal Manifestation (hematuria)
 Hepatic manifestations (jaundice, increase liver
enzymes)
Dengue without Warning Signs
(DHF Grade I)

Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT with no dark colored food
 Labs:
 CBC, plt, blood typing
 serial hct/plt Q8 or Q12
 baseline PT, aPTT
 PCR
 Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
 Dengue duo (most sensitive at 5th day of illness
onwards)
 Intravenous Therapy
 Infant <6 months old:
 D5 0.45% at maintenance rate (see Intravenous )
 Ages > 6 months old:
 D5LR or Plain LR at maintenance rate (see
Intravenous )
 IF with mild dehydration but NOT in shock, add the
following to the TFR
 ≤ 12 months old: 50 cc/kg in 24hrs
 ≥ 12 months old: 30 cc/kg in 24hrs
 Meds:
 Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥ 38°C
 I & O Qshift and record quantitatively
 Monitor V/S to include BP
 Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
 DO NOT give aspirin or ibuprofen in dengue
 For obese patients, use ideal weigh for computation of
the TFR
Dengue with Warning Signs
(DHF Grade II)
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT with no dark colored food
 Labs:
 CBC, plt, blood typing
 serial hct/plt Q8 or Q12
 baseline PT, aPTT
 PCR
 Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
 Dengue duo (most sensitive at 5th day of illness
onwards)
 IV: D5LR or Plain LR using the following rates:
 Start at 5 – 7 cc/kg/hr for 1 – 2 hours, then
 Reduce to 3 – 5 cc/kg/hr for 2 – 4 hours, and then
 Reduce to 2 – 3 cc/kg/hr or less according to
response
 Meds:
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
 Ranitidine 3 mg/kg/day IVTT Q8 PRN for epigastric
pain
 Vitamin K 3 – 5 mg; PRN for bleeding
 Tranexamic acid 15 – 20 mg/kg Q6 for bleeding
 I & O Qshift and record quantitatively
 Monitor V/S to include BP
 Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
 DO NOT give aspirin or ibuprofen in dengue
 For obese patients, use ideal weigh for computation of
the TFR
Severe Dengue
(DHF Grade III – Compensated Shock)
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT with no dark colored food
 Labs:
 CBC, plt, blood typing
 serial hct/plt Q8 or Q12
 baseline PT, aPTT
 PCR, AST, ALT
 Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
 Dengue duo (most sensitive at 5th day of illness
onwards)
 IV: Plain LR using the following rates (see
Recommended Fluid Therapy for Compensated Shock)
 Start at 10 cc/kg/hr over 1 hour, if with improvement
 Regulate to 5 – 7 cc/kg/hr for 1 – 2 hours, then
 Reduce to 3 – 5 cc/kg/hr for 2 – 4 hours, and then
 Reduce to 2 – 3 cc/kg/hr or less according to
response
 Meds:
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
 Ranitidine 3 mg/kg/day IVTT Q8 PRN for epigastric
pain
 Vitamin K 3 – 5 mg; PRN for bleeding
 Tranexamic acid 15 – 20 mg/kg Q6 for bleeding
 I & O Qshift and record quantitatively
 Monitor V/S to include BP
 Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
 Colloid fluids maybe started anytime during the fluid
resuscitation
 Dopamine may be started in separate line if maximum
of 60 cc/kg of PNSS is administered (or equivalent to 3
pushes of 20 cc/kg)
 FWB or PRBC transfusion is needed if loss or on-going
loss is significant.
 DO NOT give aspirin or ibuprofen in dengue
 For obese patients, use ideal weigh for computation of
the TFR
Recommended Fluid Therapy for Compensated
Shock
Severe Dengue
(DHF Grade IV – Hypotensive Shock)
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT with no dark colored food
 Labs:
 CBC, plt, blood typing
 serial hct/plt Q8 or Q12
 baseline PT, aPTT
 PCR, AST, ALT
 Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
 Dengue duo (most sensitive at 5th day of illness
onwards)
 IV: Plain LR using the following rates (see
Recommended Fluid Therapy for Hypotensive Shock)
 Push 10 cc/kg/hr over 15 minutes, if with
improvement
 Regulate to 10 cc/kg/hr over 1 hour, then
 Regulate to 5 – 7 cc/kg/hr for 1 – 2 hours, then
 Reduce to 3 – 5 cc/kg/hr for 2 – 4 hours, and then
 Reduce to 2 – 3 cc/kg/hr or less according to
response
 Meds:
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
 Ranitidine 3mg/kg/day IVTT Q8 PRN for epigastric
pain
 I & O Qshift and record quantitatively
 Monitor V/S to include BP
 Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
 Colloid fluids maybe started anytime during the fluid
resuscitation
 Dopamine may be started in separate line if maximum
of 60 cc/kg of PNSS is administered (or equivalent to 3
pushes of 20 cc/kg)
 FWB or PRBC transfusion is needed if loss or on-going
loss is significant.
 DO NOT give aspirin or ibuprofen in dengue
 For obese patients, use ideal weigh for computation of
the TFR
Recommended Fluid Therapy for Hypotensive Shock
Interpreting Hematocrit Changes

 rising or persistently high hct with unstable vital signs


(esp. narrowing of the pulse pressure)
 indicates active plasma leakage
 need for a further bolus of fluid replacement
 rising or persistently high hct with stable hemodynamic
status and adequate urine output
 does not require extra IVF
 continue to monitor closely
 it is likely that the hct will start to fall within the next
24 hours as the plasma leakage stops
 decrease in hct with unstable vital signs (particularly
narrowing of the pulse pressure, tachycardia,
metabolic acidosis, poor urine output)
 indicates major hemorrhage and the
 need for urgent blood transfusion
 A decrease in hct with stable hemodynamic status
and adequate urine output
 indicates hemodilution and/or reabsorption of
extravasated fluids,
 IVF must be discontinued immediately to avoid
pulmonary edema
Management of Dengue
Outpatient:
History of fever 2-7 days duration, skin flushing or rash
and/or positive tourniquet test, with no danger signs
 Give
 Oresol to replace fluid as in moderate dehydration
at 75 mL/kg BW in 4-6 hours or up to 2 – 3 liters in
adults
 Oresol PLAN B (Replace fluids in 4-6 hours)
 < 4 mos or < 6 kg
 200 – 400 mL
 4 – 12 mos or 6 – 10 kg
 400 – 700 mL
 1 – 2 years or 10 – 12 kg
 700 – 900 mL
 2 – 5 years or 12 – 19 kg
 900 – 1400
 Paracetamol for fever
 Do not use Ibuprofen or Aspirin
 Monitor
 Assess patient for danger signs daily
 Get platelet count an d HCT once a day until
patients become afebrile for 72 hours ;
 May include bleeding time if platelet count or hct
are not available
 Watch out for any danger signs
 Disposition
 Send patient home
 Ask patient to follow-up daily until 72 hours afebrile
or immediately refer if there is any danger sign
In-patient:
 Presence of 1 or more DANGER SIGNS (especially
during defervescence):
 Spontaneous bleeding
 Persistent vomiting
 Restlessness
 Change in mental status
 Weak, rapid pulse
 Cold, clammy skin
 Circumoral cyanosis
 Difficulty of breathing
 Seizures
 Hypotension or narrowing of pulse pressure (<20
mmHg)
 Platelet count < 100,000 cells/mm2
 Hemoconcentration (rise in >20% above average or
20% following treatment with fluids as compared to
baseline)
 Prolonged bleeding time (> 5min by Ivy method)
 When patient is not in shock:
 Start IVF preferably D5LR or D5 0.9% NaCl or Plain LRS
at 5 – 7 mL/kg/hr for 3 hours
 If there is improvement
 reduce IVF at 3 mL/kg/hr (up to 2-3 liters per day in
adults) and
 Maintain at same rate for 24 – 48 hours using D5
LRS alternating with D5IMB (<2 yo) or D5NM or D5
0.3NaCl (>2 yo)
 If there is NO improvement
 increase IVF rate by 3 – 5 mL/kg/hr increments up
to 15 mL/kg/hr then
 adjust accordingly as above
 When patient is in shock:
 IVF: crystalloids-PLR or PNSS 0.9 at 20 mL/kg IV bolus
in <20 mins (20/20 rule)
 If there is NO improvement
 Follow up with colloids (Dextran, Heamacel,
Haesteril) at 10 – 30 mL/kg in < 20 mins
 Give whole blood (20 mL/kg) when there is gross
bleeding or significant blood loss; when blood loss
is 25% or more of the blood volume and when Hct
falls by 20% (>10% blood loss I adults or >25% bolos
loss in pediatrics of total blood volume at 80
mL/kg)
 Giver packed red cells (10 mL/kg) when blood loss
<25% of the blood volume
 Give fresh frozen plasma (15 mL/kg) in patients
with prolonged PT (2x the control) and/or in
patients in impending shock despite crystalloids
infusion in the absence of colloids
 Give cryoprecipitate (1 unit/5 kg) if with prolonged
aPTT:
 >50 secs if with no reference value
 10 secs more than the upper limit of normal
 20 secs more than the control
 Signs of DIC
 May give platelet concentrate (1 unit/7 kg) if
 Platelet count is <50,000 in a patient with
significant bleeding
 Platelet count of <20,000 in patient with no
bleeding
 Giver oxygen, correct metabolic acidosis
 Monitor
 Request for initial CBC, platelet count, bleeding
time, blood typing, PT, aPTT
 Take HCT asfrequent as necessary for serious cases
until normal for age
 Take platelet count:
 If >50,000, monitor once a day until an increasing
trend is established
 if < 50,000, monitor frequently until >50,000
 Monitor VS Q2hours
 Monitor urine output and level of consciousness
 OPTIONAL
 CXR, ECG, ABG, Liver UTZ
 Total protein
 Albumin
 Globulin, SGPT
 Urinalysis
 Creatinine for patients in shock that require
assessment of renal function
 Disposition
 Transfer/admit to hospital
 Discharge/send patient home if :
 2 - 3 days after complete recovery from critical
stage (Shock)
 Symptom-free or absence of danger signs, good
appetite, good urine output, no signs of bleeding
(at least on 2 occasions)
Summary of Blood Component Therapy
Type Amount or Indications:
Volume
 Platelet of ≤ 50,000/cu
mm with bleeding
Platelet 1 unit / 7 kg as
 Platelet if ≤ 20,000/cu
concentrate fast drip
mm with or without
bleeding
 either the PT or APTT is
at least twice higher
than the highest normal
10 – 20 mL/kg in value
3 hours  can also use as colloid
FFP
(coagulation at a dose of 10-20
purposes) ml/kg in rapid infusion in
patients in impending
shock despite
crystalloids.
 if significant blood loss is
suspected based on
10 15 mL/kg in
PRBC low hematocrit (blood
4 hours
loss <25% of the blood
volume)
 gross bleeding or
significant blood loss;
when blood loss is 25%
or more of the blood
15 – 20 mL/kg in
FWB volume and when Hct
4 hours
falls by >25% blood loss
in pediatrics of total
blood volume at
80ml/kg
 aPTT is twice higher
Cryoprecipitate 0.1 – 0.2 units/kg
than normal
Typhoid Fever
Definition
 Typhoid fever, the most frequent enteric fever, is a
systemic infection caused by S. typhi. It tends to be
more severe than the other forms of enteric fever.

Transmission
 Ingestion of contaminated food and water

Incubation period
 For gastroenteritis usually is 12 to 36 hours (max 6 to
72 hours).
 For enteric fever, the incubation period is usually 7 to
14 days (as high as 3 to 60 days).

Symptoms:
School-age Children and adolescents:
 Pea soup diarrhea followed by constipation
 Fever (rises in a stepwise fashion)
 malaise
 anorexia
 myalgia
 headache
 abdominal pain develop over 2-3 days

Complications:
 Intestinal perforation
 GI hemorrhage
 Peritonitis
 Hepatic or splenic abscess
 DIC, myocarditis, meningitis
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT
 Labs:
 CBC, plt
 Serum Na, K
 Culture (Blood; urine- second week; Stool- third
week)
 Typhi Dot (if illness is 4 days or above)
 Malarial smear (for differential)
 IVF: D5LR or D5IMB at full maintenance rate
 Meds:
 Fully susceptible strains
 Chloramphenicol 100mg/kg/day IVTT Q6 x 14 days;
OR
 Cotrimoxazole 8-10 mg/kg/day PO Q12 x 14 days;
OR
 Amoxicillin 75-100 mg/kg/day PO TID x 14 days; OR
 Cefixime 50-75mg/kg/day PO BID x 14 days

 Quinolone/Multidrug-resistant strains
 Azithromycin 8-10 mg/kg/D PO OD x 7 days; OR
 Ceftriaxone 100mg/kg/day IVTT OD or Q12 x 5-7
days ( ) ANST; OR
 Cefixime 20 mg/kg/day PO BID x 14 days; OR
 Ofloxacin/Ciprofloxacin 15mg/kg/day x 14 days
 Supportive Therapy
 Paracetamol 15mg/kg/dose PO Q4 pm for temp ≥
38°C
 Monitor V/S Q4
 Refer for persistent abdominal pain, DOB, change of
sensorium, seizure or any untoward events
Bacterial Skin & Soft Tissue Infection
Definition:
 single most common diagnosis among children with
skin problems. The most common bacterial skin
infection in children is impetigo, which makes up
approximately 10% of all skin problems.

Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT
 Labs
 CBC, plt
 CXR AP/L
 IV: D5LR or D5IMB at full maintenance rate
 Meds:
 Punctured wounds (P. Aeuruginosa, S.aureus,
Streptococcus, Anaerobes)
 Oxacillin 100-200 mg/kg/day slow IVTT Q6 ( )ANST
PLUS
 Amikacin 15mg/kg/day IVTT OD OR
 Ceftazidime 100mg/kg/day IVTT Q6 ( ) ANST

 Classical Impetigo (S. pyogenes)


 Cloxacillin 50-100 mg/kg/day slow IVTT Q6 OR
 Oxacillin 100-200 mg/kg/day slow IVTT Q6 ( )ANST

 Bullous Impetigo, Furunclosis, Carbuncle (S. aureus)


 Cloxacillin 50-100 mg/kg/day slow IVTT Q6 OR
 Oxacillin 100-200 mg/kg/day slow IVTT Q6 ( )ANST

 Pyoderma/Abscess (S. aureus, Streptococcus spp.)


 Cloxacillin 50-100 mg/kg/day IVTT Q6 ( ) ANST OR
 Oxacillin 100-200 mg/kg/day IVTT Q6 ( )ANST
 Buccal cellulitis (H. influenza, S. pneumoniae)
 Chloramphenicol 100 mg/kg/day IVTT Q6 OR
 Cefotaxime 100 mg/kg/day IVTT Q6 ( ) ANST OR
 Ceftriaxone 100 mg/kg/day IVTT Q12 ( ) ANST

 Necrotizing Fascitis (S. pyogenes, S. aureus, Gram(-)


bacilli)
 Penicillin G 100,000-300,000 Units/kg/day mixed
with 30cc PNSS to run as drip Q6 ( )ANST
 Clindamycin 20-40 mg/kg/day IVTT Q6 OR
 Metronidazole 30 mg/kg/day IVTT 08 PLUS
 Amikacin 15 mg/kg/day IVTT OD

 Pyomyositis (S. aureus, Spyogenes), Scalded Skin


Syndrome (S. aureus), Suppurative
Lymphadenitis/lymphangitis (Streptococcus spp, S.
aureus)
 Oxacillin 100-200 mg/kg/day slow IVT Q6 ( )ANST;
OR
 Cloxacillin 50-100 mg/kg/day Q6 ( )ANST

 Gas Gangrene (C. perfringens, Anaerobes, S.


pyogenes, S. aureus)
 Penicillin G 100,000-300,000 Units/kg/day mixed
with 30cc PNSS to run as drip Q6 ( )ANST OR
 Clindamycin 25-40 mg/kg/day Q6
 Refer for persistent fever, progress of pain or any
untoward events
 Refer to surgery for surgical evaluation and
management
Tetanus
Definition
 Tetanus (lockjaw) is an acute, spastic paralytic illness
caused by tetanus toxin (tetanospasmin), the
neurotoxin produced by Clostridium tetani.
Source
 Soil, dust, animal or human feces, plaster, unsterile
suture, rusty scissors, nails, pins, ashes
Transmission
 Spores of the bacteria are usually introduced in an
area if injury or wounds, disease develop only after
spores are converted to vegetative forms which
produce tetanospasmin under conditions of
reduced ambient oxygen.
 Usually a non-immunized person develops a skin
injury and comes into contact with infected soi1.
Incubation period:
 Typically 2-14 days, but it may be as short as 1 day or
as long as months after the injury.
Pertinent History
 NEONATES:
 Umbilical cord stump cut by contaminated scissors
or other devices like blades or bamboo; application
of ashes or leaves on the cord for dressing; absence
of maternal tetanus toxoid injection.
 OLDER CHILDREN:
 Direct or indirect contamination of obvious or
unrecognized wounds; a relatively common
unrecognized wounds which includes injury by dirty
or rusty hair-pins used in cleaning external auditory
canal, tooth picking or dental carries which may
serve as a portal of entry; absence of tetanus toxoid
in early childhood
Manifestations:
 Generalized tetanus: most common form
 NEONATES:
 onset between 3-10 days old, with poor suck and
poor cry
 jaw becomes too stiff so that baby cannot suck
nor swallow
 variable degrees of sustained tonic or rigid states
of muscle contractions, spasms or convulsions,
occurring spontaneously or provoked by stimuli
such as noise, light and/or touch
 Opisthotonus may or may not be present; deep
tendon reflexes may be exaggerated or show no
response when tonic seizures are sustained; spasms
of expiratory muscles can lead to episodes of
apnea
 Cry varies from repeated short, mildly hoarse cry to
strangled sounding voiceless noise
 Constipation and urinary retention are common
 Cyanosis or pallor may be observed
 May end with flaccidity, anoxia, exhaustion and
finally death
 OLDER CHILDREN:
 Onset is insidious
 Progressive stiffening of voluntary muscles
becoming stiff within 24 hours
 The usual sequence of muscle involvement is as
follows:
 Jaw: trismus or locked jaw
 Neck and back: opisthotonus
 Face: sardonic smile or risus sardonicus
 Trunk: board-like abdomen
 Extremities: stiff and extended
 In severe cases: respiratory muscle and
laryngeal muscles cause accumulation of
secretions in the lower airway and respiratory
distress
 Spasms stimuli: touch, bright light, noise or
movement of patient
 Fever: usually absent but may be as high as
40°C because of energy generated by titanic
seizures
 Sensorium: usually intact, clear
 Cephalic Tetanus: involvement of the CN III, IV, VII, IX
and XI. However, CN VII is affected most frequently.
 Shorter incubation period
 Follows a head injury, otitis media or foreign bodies
in the nose
 May precede generalized tetanus or remain
localized
 Prognosis is poor
 Localized Tetanus:
 Painful spasms of muscles in proximity to the site of
injury which may persist for weeks and disappear
without sequelae
 Occasionally precedes development of generalized
disorder
Tetanus Neonatorum Scoring (TNS): assess the prognosis at
time of admission and subsequently
Score 0 1 2 3
Age of onset of
symptoms 1–4 5–8 9 – 12 >12
(days)
Interval No
between <12 24 – 48 >48 spontaneous
spasms (hours) spasms
Spasms duration Persistent Transient or on
>2 <2
(minutes) prolonged stimulation
Temperature
variation from >3 >2 - <3 >1 - <2 Normal ± 1
normal
Pneumonia
Definite Definite Suspected
and/or Nil
widespread limited mild
atelectasis

Interpretation of TNS:
Score of 0 : recovery improbable
Score of 15 : recovery expected
NOTE: Reassessment of TNS should be done every 24 hours
Sample Orders:
 Please admit to Isolation
 Secure consent
 TPR Q2
 NPO temporarily
 Labs:
 CBC, plt
 Na, K
 CXR APL
 RBS
 IV: D5LRlLi to run as maintenance rate
 Meds:
 To neutralize circulating toxin
 For NEONATES:
 TIG 3,000 Units IM OR
 ATS 5,000 Units IM and another 5,000 units IVTT
 For OLDER:
 TIG 3,000 Units IM OR
 ATS 10,000 Units IM and another 10,000 units IVTT
( ) ANST
 Tetanus toxoid 0.5 cc IM
 To eradicate vegetative forms of C. tetani
 Penicillin 100 mg/kg/day IVTT OR as drip Q6
( ) ANST OR
 Metronidazole 30 mg/kg/day IVTT Q8
 To control muscular spasms*
 Diazepam 0.2mg/kg/dose slow IVTT Q2hours
 May consider Midazolam drip 1-2ugm/kg/hr
 To provide other supportive and symptomatic care
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥ 38°C
 Ranitidine 2-4 mg/kg/day IVTT Q8
 Debridement of necrotic tissues (refer to surgery)
 1 & O Q shift and record quantitatively
 Monitor V/S but avoid stimuli (tactile, noise, light)
 Clean wound with hydrogen peroxide and betadine
 Refer for uncontrolled spasms
 May need to refer to anesthesia for sedation
 Secure airway either thru intubation or tracheostomy
 Once intubated, hook to mechanical ventilator if
available

*CAUTION:
 Using of Diazepam and Midazolam especially with
inappropriate dosaging may cause respiratory
depression. It warrants close monitoring of the patient’s
condition.
 If the treating physician is not confident enough to
manage the case, referral to higher level of health
care may be the appropriate move.
Malaria
Definition
 Malaria is the most common acute and chronic
parasitic disease in humans characterized by
paroxysms of fever, chills, sweats, fatigue, anemia
and splenomegaly.
Etiology
 plasmodium falciparum (most frequent)
 plasmodium vivax
 mixed infection (Pf and Pv)
 plasmodium malariae
 plasmodium ovale (rare)
Common symptoms
 fever and chills
 splenomegaly
 anemia
Control and preventive measures
 Treatment of infected persons
 Chemoprophylaxis for travelers to endemic area
 Reduction of contact with mosquitoes through the
use of insect repellents, protective clothes, mosquito
nets and screens
 Eradication of Anopheles mosquitoes through the
use of insecticides and other measures
Geographical Distribution
 generally considered rural in distribution
 seen mostly in hinterlands and newly opened
settlement areas
 local experience show cases reported in areas
adjacent to urban centers
 cases in Western Mindanao are common from island
provinces of ARMM like Basilan, Sulu (Tongkil) and
Tawi-tawi.
Malaria: Diagnostic Approach
Sample Orders:
 Please admit
 Secure consent
 TPR Q4
 DAT
 Labs:
 CBC, plt, blood type
 CXR AP/L
 Malarial Smear or
 ICT-Malaria
 Baseline BUN, Creatinine, liver function tests,
 IV: D5LR or D5IMB at full maintenance rate
 Meds:
 Uncomplicated P. falciparum Malaria
 Coartem tab:
For weight 25kg to less than 35kg- needs 18 tabs
 3 tabs PO, then 3 tabs after 8 hrs, then 3 tabs BID
for 2 days
For weight 15kg to less than 25kg- needs 12 tabs
 2 tabs PO, then 2 tabs after 8 hrs, then 2 tabs
BED for 2 days
For weight 5kg to less than 15kg- needs 6 tabs
 1 tabs PO, then 1 tabs after 8 hrs, then 1 tabs
BED for 2 days
 Primaquine (26.3 mg or 15 mg base tablet) on Day
3 ONLY
 Above 12 years old : 3 tabs
 7-11 years old : 2 tabs
 4-6 years old : 1 tab
 1-3 years old : ½ tab
 Below 1 year old : contraindicated
 Uncomplicated P. vaxix Malaria
 Chloroquine-sensitive P. vivax, P. Ovale,
P.falciparum:
 Chloroquine 10mg base/kg PO initially for Day 0
and 1; then 5mg base/kg on Day 2; PLUS
 Primaquine 0.3 mg base/kg PO daily for Day 3-
17 (for vivax and ovale)
 Chloroquine-resistant plasmodium and severe P.
falciparum:
 Quinine dihydrochloride 20 mg/kg in 500cc D5W
or NSS over 4 hours initially, then 10 mg/kg in
500cc D5W or NSS as drip over 4 hours Q8 hours.
 Shift to oral quinine sulfate 10 mg/kg TID as soon
as oral drugs are tolerated to complete 7 days
of treatment
 Refer for abdominal pain, change of sensorium, DOB,
seizure or any untoward events
Meningococcemia
Definition
 Meningococcemia is a result of invasive
meningococcal infection in which the onset is
abrupt.
Etiology
 Neisseria meningitides
 a gram negative diplococcus with at least 13
serogroups. This is thought to be acquired by a
respiratory route.
Incubation Period
 1 – 10 days, but an average of less than 4 days
Clinical Manifestations: Mimics viral infections
 pharygitis
 fever
 chills
 malaise
 macular, maculo-papular or petechial rashes in
rapid progression
 In fulminant cases: plus ― Waterhouse-Friderichsen
Syndrome
 Purpura
 DIC
 Shock
 Coma
 Death : despite of appropriate management
Sample Orders:
 Please admit in isolation
 Secure consent
 TPR Qhourly
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 Na, K
 Blood C/S
 Gram staining (purpuric scrapping)
 CSF Analysis
 IV: D5LR or D5IMB at full maintenance rate + 12%
 Meds:
 Penicillin 100,000-300,000 Units/kg/day mixed with
20cc PNSS to run as drip Q6 ( )ANST
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
 Diazepam 0.2 mg/kg/dose slow IVTT PRN for frank
seizure*
 For succeeding seizure episodes*
 ADD: Phenobarbital 10mg/kg slow IVTT, then
repeat another 10mg/kg slow IVTT 30mins after
the first dose, then give maintenance dose of 5
mg/kg/day slow IVTT Q12
 Ranitidine 2-4mg/kg/day IVTT Q8
 O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM
 Monitor V/S Q4 to include O2 saturation
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
 For SHOCK:
 Push 20cc/kg PNSS IV bolus (may repeat upto 3x if
still with no pulse)
 Dopamine may be started in separate line if
maximum of 60cc/kg of PNSS bolus is already
administered
Viral Exanthem
A rash associated with a viral infection; it may be caused
by an immune hyper-reaction or by the toxins released
by the virus. It is usually widespread across the body
and can vary in characteristics depending on the virus
involved. Some causes are self-limiting while others
may require supportive or specific treatment.

Sample orders for measles


 Please admit to isolation
 Secure consent
 TPR Q2
 DAT (continuer breastfeeding)
 Labs:
 CBC plt
 CXR AP/L
 IV: D5 IMB at full maintenance
 Meds:
 Vitamin A (according to Adjunct management for
diarrhea)
 Treat secondary infection like pneumonia if
warranted
 O2 inhalation via nasal cannula at 2LPM (if warranted)
 Monitor V/S
 Inform DOH/City Health office for appropriate
preventive measures to those who were exposed
 Refer accordingly
Urinary Tract Infection (UTI)
Definition:
 UTI is one of the most common bacterial infections
and a common cause of febrile illness in children
that may indicate underlying disease of the renal
tract.

Basic forms of UTI:


 Pyelonephritis
 Upper UTI that is characterized by any or all of the
following: abdominal pain or flank pain, fever,
malaise, nausea, vomiting, jaundice in neonates,
and occasionally diarrhea.
 Some neonates and infants may show poor feeding,
irritability and weight loss.
 Cystitis
 Lower UTI that is characterized by dysuria, urgency,
frequency, suprapubic pain, incontinence and
malodorous urine.
 Usually does not cause fever.
 Asymptomatic bacteriuria
 Refers to children who have a positive urine culture
without any manifestations of infection
 Occurs almost exclusively in girls.

Etiology:
 E. coli - 80-90%
 Others include
 Klebsiella species, Enterobacteria species
 Coagulase negative Staphylococcus
 Uncommon organisms causing UTI in ambulatory
children
 H. influenza, Adenoviruses, Enterococci
 Post- instrumentation
 Proteus, Pseudomona, Staphulococcus aureus,
Streptococcus, Enterococcus and Klebsiella
Approach to Urinary Tract Infection

**timing depends on discretion of the specialist


Sample Orders:
 Please admit
 Secure consent
 DAT
 TPR Q4
 Small frequent feeding
 Labs:
 CBC, plt
 Urinalysis
 Urine culture (if available)
 Creatinine (as needed)
 KUB UTZ (as needed)
 IV: D5LR or D5IMB at full maintenance rate
 Meds:
 Neonates:
 Ampicillin 100mg/kg/day IVTT Q12 ( ) ANST PLUS
 Gentamycin 5mg/kg/day IVTT OD OR
 Cefotaxime 100mg/kg/day IVTT Q6
 For Older Children:
 Ceftriaxone 100 mg/kg/day IVTT Q12 ( ) ANST OR
 Cefotaxime 100mg/kg/day IVTT Q6 ( ) ANST
 Paracetamol 15mg/kg/dose PO Q4 PRN for temp ≥
38
 I & O Q shift and record quantitatively
 Refer for hypertension, seizure, persistent abdominal
pain, persistent vomiting or any other untoward events.
Nephrology
Doctors’ Guide
Nephrotic Syndrome (NS)

Definition:
Is a clinical syndrome characterized by generalized
edema/anasarca, heavy proteinuria (albuminuria),
and hypoalbuminemia, with or without
hypercholesterolemia/hyperlipidemia. It is important
that heavy proteinuria is quantified to make a
definitive diagnosis. By definition, heavy proteinuria is
40mg/m2/hr in a 24 hour urine collection. You may
suspect nephrotic syndrome if albumin in the dipstick is
3+ or 4+. Hypoalbuminemia is defined as albumin
<25g/L.

See Nephrotic vs Nephritic Syndromes

Sample Orders:
 Please admit
 Secure consent
 TPR Q2 to include BP
 Diet:
 Low salt, low fat diet
 Encourage egg white intake
 Labs:
 CBC, plt, blood typing
 Urinalysis
 CXR AP/L (if pleural effusion is considered)
 TPAG
 Serum cholesterol
 Serum creatinine
 Serum Na, K
 Serum C3
 No fluid restriction is necessary unless with signs of
volume overload (neck vein engorgement,
hypertension, pulmonary congestion, congestive heart
failure). If necessary initially limit fluid at 500mL/BSA/day
(orally)
 7-3 shift = 45% of computed fluid
 3-11 shift = 45% of computed fluid
 11-7 shift = 10% of computed fluid
 Meds:
 If free from infection
 Prednisone 60mg/m2/day or 2mg/kg/day PO OD
(max of 60mg/day)
 Antibiotics coverage (if needed according to
specific consideration)
 O2 inhalation either nasal cannula at 3 LPM (if
necessary)
 Transfusions (if necessary)
 Transfuse human albumin 1-2gm/kg/dose as drip for
1-2 hours
 Give furosemide 0.5-1mg/kg/dose SIVP mid and
post blood transfusion
 I & O Q shift and record quantitatively
 Provide empty IV bottle to watcher for purpose of
urine measurement.
 Refer for hypertension, cyanosis, seizure, DOB and
other untoward events
Acute Glomerulonephritis (AGN)

Definition:
AGN is a clinical pattern characterized by an acute
onset of degrees of hematuria, hypertension, edema,
and oliguria. A history of pharyngitis or
impetigo/pyoderma, 1-3 weeks prior to the clinical
manifestation is usually present.

See Nephrotic vs Nephritic Syndromes

Sample Orders:
 Please admit
 Secure consent
 TPR Q2 to include BP
 Diet:
 Low salt, low fat diet
 Labs:
 CBC, plt, blood typing
 Urinalysis with RBC morphology
 ASO titer (if financially able)
 Serum C3 complement (if available)
 CXR AP/L (if pulmonary congestion is considered)
 Fluid Restriction (orally)
 Ideal Computation: 500cc/BSA/day (may
discontinue restriction if normotension is achieved)
 7-3 shift = 45% of computed fluid
 3-11 shift = 45% of computed fluid
 11-7 shift = 10% of computed fluid
 Meds:
 Phenoxymethylpenicillin K (Sumapen) 50mg/kg/day
PO Q6
 Furosemide 1-2mg/kg/day IVTT Q4-6
 Nifedipine 0.6-1mg/kg SL PRN for hypertension (BP ≥
P99 of the normal BP range for age, sex, and height,
or if patient is symptomatic – with headache, seizure,
blurring of vision)
 If hypertension is not yet controlled:
 May add Captopril 0.3-0.5mg/kg/dose PO Q8hrs
 O2 inhalation either nasal cannula at 3 LPM (if
necessary)
 I & O Q shift and record quantitatively
 Provide empty IV bottle to watcher for purpose of
urine measurement.
 Refer for hypertension, cyanosis, seizure, DOB and
other untoward events

NOTE
Phenoxymethylpenicillin K (Sumapen) 50mg/kg/day PO
Q6 is currently nor routinely recommended.
Technically, you do not have to treat the infection
since it is POST-INFECTIOUS. However, if the patient is still
febrile or toxic looking you may opt to give to treat the
possible nephritogenic strains
Neonatology
Doctors’ Guide
Ballard Score
Problems in the neonates
 About 99% of all newborns are considered well-baby,
thus skills on Essential Intrapartum Newborn Care (EINC)
is a MUST
 About 1% require extensive resuscitation efforts, thus
health workers should require Neonatal Resuscitation
Program (NRP) training
 Approximately 10% require some assistance after birth.
With this, competencies on what to carry out (whether
EINC or NRP) are very important
 Most of the newborns underwent extensive
resuscitation and few of those delivered well baby
(e.g. with imperforated anus) may need transfer to
other hospital, thus, health worker must also need to
know the neonatal transport program known as STABLE
(Sugar, Temperature, Airway, Blood pressure,
Laboratory works, Emotional support)

BIRTH

 Term gestation?
YES
 Clear amniotic fluid? See Essential Intrapartum
 Breathing/crying? Neonatal Cure (EINC)
 Good muscle tone?

NO

See Neonatal TRANSFER to other


Resuscitation Program hospital is NEEDED

See S.T.A.B.L.E
Neonatal Resuscitation Program

NOTE
 NRP, 2010 removes the question regarding amniotic
fluid in the initial assessment of the program. However,
this clue may still be as relevant in our setting
1. Initial steps of resuscitation:
―WADS-R‖ (Warmth, Airway clearing, Dry, Stimulate,
Reposition)
Initial Steps Important Inputs
 The goal is to achieve normothermia and avoid
iatrogenic hyperthermia
 VLBW infants need additional warming techniques
such as covering them with plastic wrapping and/or
Warmth/
placing them under radiant heat.
Temperature
 Other techniques to maintain temperature in the
Control
delivery room are drying, warming pads, increased
environmental temperature, and if the baby is stable,
placing him/her skin-to-skin with the mother covered
with a blanket (EINC)
 Routine intrapartum oropharyngeal suctioning is no
longer routinely recommended for newborns born to
Airway mothers with meconium stained amniotic fluid.
Clearing of  ONLY non-vigorous newborns (poor respiratory effort,
Meconium heart rate < 100bpm, poor muscle tone) require
endotracheal suctioning (DO NOT do PPV to these
newborns).
 Dry the newborn completely and discard the wet
linens, including those upon which the newborn is
lying.
Dry
 Drying should be thorough but gentle, avoid vigorous
rubbing or attempts to clean all blood or vernix from
the body.
Stimulate  Drying is a form of stimulation
 Place the newborn with head in midline position with
Reposition
slight neck extension
NOTE
 Do periodic evaluation of respiration, heart rate and color at 30 seconds
interval after the immediate post-delivery assessment. It may take
>10minutes for the newborn to achieve good color
NOTE
 Administration of oxygen depends on the assessment of the physician
based on respiration and color. Further resuscitative measure should be
guided also by assessment of respiration, heart rate and color,
2. Positive Pressure Ventilation (PPV)

Indications:
 Newborn remains apneic or gasping
 If the heart rate remains <100bpm 30 seconds after
administering the initial steps OR
 The newborn continues to have persistent central
cyanosis despite administration of oxygen
supplementation

Important inputs
Devices Initial Breaths and Assisted Assisted Ventilation for the
Ventilation Preterm
1. Flow inflating  Initial peak inflating  Most preterm infants
bag pressure for the initial can be ventilated with
2. Self-inflating breath 30-40cm H2O an initial inflation
bag and 20-30cm H2O for pressure of 20-25 cm
3. T-piece subsequent breaths H2O although of some
resuscitator  Assisted breaths 40-60 who do not respond
4. Laryngeal per minute is require a higher
mask commonly used pressure
 Primary measure of  Prompt improvement
adequate response to in heart rate should be
assisted ventilation is obtained
prompt improvement
in heart rate of
>100bpm
CAUTION: Never do PPV for meconium aspirated newborn
and for newborn with congenital diaphragmatic
hernia.
3. Endotracheal Intubation:

Indications:
 Tracheal suctioning for meconium is required.
 Bag-mask ventilation is ineffective or prolonged
 Chest compressions are performed
 Endotracheal administration of medication is desired
 Special circumstances: Congenital Diaphragmatic
Hernia or extremely low birth weight (< l,000 g)

NOTE:
 Prompt increase in heart rate is the BEST indicator of
correct tube placement and effective ventilation
Predicted Endotracheal tube (ETT) Size & Depth according
to Weight and Gestational Age
ETT Depth (cm
Gestational Age Weight ETT size Laryndoscope Blade
from the upper
(weeks) (gm) (mm) (Straight/Miller)
lip)
24 700 2.5 7 < 1,000 gm
26 900 2.5 7 Size #00
28 1,100 2.5 – 3.0 7
1,000 – 2,000 gm
30 1,350 3.0 7
Size #0
32 1,650 3.0 7
34 2,100 3.5 8
>2,000 gm
36 2,600 3.5 8
Size #1
38 3,000 3.5 – 4.0 9

Formula for ETT depth (mm) = Weight (kg) + 6


Eg. Weight is 3kg, so 3 + 6 = 9
ETT depth is 9mm level
4. Chest Compression:

Indication:
 Heart rate of <60bpm despite adequate ventilation
with supplementary oxygen for 30 seconds.

 Location
 Lower third of the sternum
 Techniques:
 2 thumb technique
 2 thumb technique with fingers encircling the chest
and supporting the back (recommended)
 2 fingers technique
 2 fingers technique with send hand supporting the
back
 Rate
 120 events / min
 Compressions : Ventilation
 3 : 1 ratio
 90 compressions and 20 ventilation per minute
 Depth
 1/3 of the antero-posterior diameter of the chest
5. Medication
Medication Indication Route Dose
Epinephrine If heart rate remains 0.001 – 0.03
<60bpm after adequate mg/kg/dose
ventilation with 100% Intravenous Using
oxygen and chest 1:10,000
compression (0.1mg/ml)
Endotracheal
(if IV access Upto
is not 0.1mg/kg
available)
Volume When volume loss is
expander suspected or the
Plain NSS or newborn appears to be Intravenous 10ml/kg
Plain LRS in shock ( pale, poor
perfusion, weak pulse)
Naloxone For narcotic-induced
(not a routine CNS depression
part of initial
resuscitation) Heart rate and color
must be restored before
Intravenous
considering this drug
or 0.1mg/kg
Intramuscular
CAUTION: Avoid in
babies whose mother is
suspected of
having long term
exposure to opioids
Essential Intrapartum Neonatal Cure (EINC)
EINC/ENC Protocol is series of time bound,
chronologically-ordered, standard procedures that a
baby receives at birth. It contains four time-bound
interventions:
 immediate drying
 skin to skin contact followed by clamping of the
cord after 1 to 3 minutes
 non-separation of baby from mother
 Breastfeeding initiation.

EINC

This is the part of NRP 2010 where EINC protocol is


applicable. This covers approximately 99% of all births.

Rationale
 immediate drying prevents hypothermia, which is
extremely important to survival
 Delayed cord clamping until the umbilical cord stops
pulsating decreases anemia in one of every three
premature babies and prevents brain hemorrhage in
one out of two. It prevents anemia in one out of every
seven term babies
 Keeling the mother and baby in uninterrupted skin-to-
skin contact prevents hypothermia, increases
colonization with protective family bacteria and
improves breastfeeding initiation and exclusivity
 Breastfeeding within the first hour of life prevents an
estimated 19.1% of all neonatal deaths
Immediate Newborn Care (The First 90 minutes)
TIME BAND:
 At perineal bulging, with presenting part visible (2nd
stage of labor)
INTERVENTION:
 Prepare for the delivery
ACTION:
 Ensure that delivery area is draft-free and between
25 – 28⁰C using a room thermometer.
 Wash hands with clean water and soap.
 Double glove just before delivery.

TIME BAND:
 Within the 1st 30 second
INTERVENTION:
 Dry and provide warmth.
ACTION:
 Call out the time of birth
 Use a clean, dry cloth to thoroughly dry the baby by
wiping the eyes, face, head, front and back, arms
and legs.
 Remove the wet cloth.
 Do a quick check of newborn’s breathing while
drying.
NOTE:
 During the first 30 seconds:
 Do not ventilate unless the baby is floppy/limp and
not breathing.
 Do not suction unless the mouth/nose are blocked
with secretions or other material.

TIME BAND:
 If after 30 second of thorough drying, newborn is
NOT BREATHING or is gasping
INTERVENTION:
 Re-position, suction and ventilate
ACTION:
 Clamp and cut the cord immediately.
 Call for help.
 Transfer to a warm, firm surface.
 Inform the mother that the newborn has difficulty
breathing and that you will help the baby to
breathe.
 Start resuscitation protocol. (See Neonatal
Resuscitation Program)
NOTES:
 If the baby is non-vigorous (limp/floppy and not
breathing) and meconium-stained, and;
 Health worker not skilled at advanced resuscitation
(or skilled but not equipped with intubation needs):
 Clear the mouth
 Start bag/mask ventilation
 Refer and transport
 Health worker with advanced skills at resuscitation:
 Intubate the baby and provide positive-pressure
ventilation
 Refer and transport as necessary
 When appropriate, and when personnel skilled in
advanced resuscitation (intubation, cardiac
massage) are available, refer to appropriate
guidelines.

TIME BAND:
 If after 30 secs of thorough drying, newborn is
BREATHING OR CRYING
INTERVENTION:
 Do skin-to-skin contact
ACTION:
 If a baby is crying and breathing normally, avoid any
manipulation, such as routine suctioning, that may
cause trauma or introduce infection.
 Place the newborn prone on the mother’s abdomen
or chest skin-to-skin.
 Cover newborn’s back with a blanket and head
with a bonnet.
 Place identification band on ankle.
NOTES:
 Do not separate the newborn from mother, as long
as the newborn does not exhibit severe chest in-
drawing, gasping or apnea and the mother does
not need urgent medical stabilization e.g. emergent
hysterectomy.
 Do not put the newborn on a cold or wet surface.
 Do not wipe off vernix if present.
 Do not bathe the newborn earlier than 6 hours of
life.
 Do not do footprinting.
 If the newborn must be separated from his/her
mother, put him/her on a warm surface, in a safe
place close to the mother.
INTERVENTION:
 Palpate the mother’s abdomen.
 Exclude a second baby. If there is a 2nd baby, get
help. Deliver the second newborn. Manage as in
 Multi-fetal pregnancy
ACTION:
 If a baby is crying and breathing normally, avoid any
manipulation, such as routine suctioning, that may
cause trauma or introduce infection.

TIME BAND:
 1 - 3 minutes
INTERVENTION:
 Do delayed or non-immediate cord clamping
ACTION:
 Remove the first set of gloves immediately prior to
cord clamping.
 Clamp and cut the cord after cord pulsations have
stopped (typically at 1 to 3 minutes)
 Put ties tightly around the cord at 2 cm and 5 cm
from the newborn’s abdomen.
 Cut between ties with sterile instrument.
 Observe for oozing blood.
NOTE:
 Do not milk the cord towards the newborn.
 After cord clamping, ensure 10 IU IM is given to the
mother. Follow other protocols per PCPNC

TIME BAND:
 WITHIN 90 min of age
INTERVENTION:
 Provide support for initiation of breastfeeding
ACTION:
 Remove the first set of gloves immediately prior to
cord clamping.
 Leave the newborn on mother’s chest in skin-to-skin
contact.
 Observe the newborn. Only when the newborn
shows feeding cues (e.g. opening of mouth,
tonguing, licking, rooting), make verbal suggestions
to the mother to encourage her newborn to move
toward the breast e.g. nudging.
 Counsel on positioning and attachment. When the
baby is ready, advise the mother to:
 Make sure the newborn’s neck is not flexed nor
twisted.
 Make sure the newborn is facing the breast, with
the newborn’s nose opposite her nipple and chin
touching the breast.
 Hold the newborn’s body close to her body.
 Support the newborn’s whole body, not just the
neck and shoulders.
 Wait until her newborn’s mouth is opened wide.
 Move her newborn onto her breast, aiming the
infant’s lower lip well below the nipple
 Look for signs of good attachment and suckling:
 Mouth wide open
 Lower lip turned outwards
 Baby’s chin touching breast
 Suckling is slow, deep with some pauses
 If the attachment or suckling is not good, try again
and reassess.
NOTES:
 Health workers should not touch the newborn unless
there is a medical indication.
 Do not give sugar water, formula or other
prelacteals.
 Do not give bottles or pacifiers.
 Do not throw away colostrum.
 If the mother is HIV-positive, of PCPNC for special
counseling.

Diagrams of infants mouth showing good and poor


attachment to the breast
INTERVENTION:
 Provide additional care for a small baby or twin
ACTION:
 For a visibly small newborn or a newborn born >1
month early:
 Encourage the mother to keep the small newborn
in skin-to-skin contact with her as much as possible.
 Provide extra blankets to keep the baby warm
 If mother cannot keep the baby skin-to-skin
because of complications, wrap the baby in a
clean, dry, warm cloth and place in a cot. Cover
with a blanket. Use a radiant warmer if room not
warm or baby small.
 Do not bathe the small baby. Ensure hygiene by
wiping with a damp cloth but only after 6 hours.
 Prepare a very small baby (<1.5 kg) or a baby born
>2 months early for referral.

INTERVENTION:
 Do eye care
ACTION:
 Administer erythromycin or tetracycline ointment or
2.5% povidone-iodine drops to both eyes after
newborn has located breast.
 Do not wash away the eye antimicrobial.

Essential Newborn Care from 90 min to 6 hours

TIME BAND:
 From 90 Min - 6 Hrs

INTERVENTION:
 Give Vitamin K prophylaxis
ACTION:
 Wash hands.
 Inject a single dose of Vitamin K 1 mg IM. (If parents
decline intramuscular injections, offer oral vitamin K
as a 2nd line).

INTERVENTION:
 Inject hepatitis B and BCG vaccinations at birth
ACTION:
 Inject hepatitis B vaccine intramuscularly and BCG
intradermally.
 Record.

INTERVENTION:
 Examine the baby
ACTION:
 Thoroughly examine the baby.
 Weigh the baby and record.

INTERVENTION: Check for birth injuries, malformations or


defects.
ACTION:
 Look for possible birth injury:
 Bumps on one or both sides of the head, bruises,
swelling on buttocks, abnormal position of legs
(after breech presentation) or asymmetrical arm
movement, or arm that does not move.
 If present:
 Explain to parents that this does not hurt the
newborn, is likely to disappear in a week or two
and does not need special treatment.
 Gently handle the limb that is not moving.
 Do not force legs into a different position.
 Look for malformations:
 Cleft palate or lip
 Club foot
 Odd looking, unusual appearance
 Open tissue on head, abdomen or back
 If present:
 Cover any open tissue with sterile gauze before
referral and keep warm.
 Refer for special treatment and/or evaluation if
available.
 Help mother to breastfeed. If not successful teach
her alternative feeding methods

INTERVENTION:
 Cord care
ACTION:
 Wash hands.
 Put nothing on the stump.
 Fold diaper below stump. Keep cord stump loosely
covered with clean clothes.
 If stump is soiled, wash it with clean water and
soap. Dry it thoroughly with clean cloth.
 Explain to the mother that she should seek care if
the umbilicus is red or draining pus.
 Teach the mother to treat local umbilical infection
three times a day.
 Wash hands with clean water and soap.
 Gently wash off pus and crusts with boiled and
cooled water and soap.
 Dry the area with clean cloth.
 Paint with gentian violet.
 Wash hands.
 If pus or redness worsens or does not improve in 2
days, refer urgently to the hospital
NOTES:
 Do not bandage the stump or abdomen.
 Do not apply any substances or medicine on the
stump.
 Avoid touching the stump unnecessarily.
INTERVENTION:
 Provide additional care for a small baby or twin
ACTION:
 If the newborn is delivered 2 months earlier or weighs
< 1500 g, refer to specialized hospital.
 If the newborn is delivered 1-2 months earlier or
weighs 1500 - 2500 g (or visibly small where scale not
available), see Additional care for small newborns
NOTES:
 Encourage the mother to keep her small baby in
skin-to-skin contact.
 If mother cannot keep the baby in skin-to-skin
contact because of complications, wrap the baby
in a clean, dry, warm cloth and place in a cot.
Cover with a blanket. Use a radiant warmer if the
room is not warm or the baby small.
 Do not bathe the small baby. Keep the baby clean
by wiping with a damp cloth but only after 6 hours.
S.T.A.B.L.E
 STABLE is an acronym used for neonatal stabilization
focusing on the five basic physiologic areas plus
emotional support to the family before transporting the
baby to other health institution for further
management. This stands for Sugar, Temperature,
Airway, Blood pressure, Laboratory works, Emotional
support

Main indication for Transport/Transfer


Problems that often require Condition that require transport
referral to Pediatrician or to a NICU set-up
neonatologist
 AGPAR score of <7 at 5  Prematurity ≤ 34 weeks
minutes  Birth weight <2000 g
 Sepsis suspected  Respiratory distress
 Meconium present at birth and  Seizure disorders
a non-vigorous infant  Congenital anomalies
 Infant of substance using requiring specialized
mother diagnostic procedures or
 Difficult labor and/or delivery treatment
 Infant of diabetic mother  G.I. problems, including
 Maternal illness and/or fever abdominal distention and
 Abnormal transitional period vomiting
(tachypnea, chest retractions)  Bleeding disorders
 Rupture of membranes >24  Genitourinary disorders,
hours prior to delivery including oliguria or anuria
 Congenital anomalies  Cardiac abnormalities
 Near term infants (35 to 37  Severe hemolysis and jaundice
weeks gestation)  Surgical conditions
 Low birth weight, between  Central cyanosis
2000-2500grams  Perinatal asphyxia
 Cardiac murmur  Severe birth trauma
 Unequal breath sounds  Evidence of infection
 Need for specialized  Flaccid infant/poor tone
diagnostic studies (MRI, CT  Suspected metabolic disorders
scan)  Generalized pallor
 Symptomatic withdrawal in
infant of substance using
mother
 Pneumothorax
TRANSPORT of SICK NEONATE
 After deciding to transfer out the neonate to other
health institution, general information and consent
from the parents must be obtained and
documented. Referral communication must be
prepared with pertinent information about the
problem of the neonate and the main reason why
the neonate is being referred.
 Stabilization prior to transport minimizes the risk of
adverse events occurring en route to the referral
center. Careful stabilization prior to transport
improves long-term outcome for the neonate.
Therefore, ensure that the sick neonate is STABLE
before during transport and upon endorsement to
the health staff of the referral center
Basic High Risk Condition Action
Physiologic
Area
S.T.A.B.L.E
Sugar SGA,  Avoid enteral feeding (PO or NG) in
premature, sick or stressed infants
IDM, LGA,  Administer IV fluid: D10W at
sick and 80cc/kg/day
stressed  Maintain blood glucose: 50-
neonates 110mg/dL
 Give IV bolus of D10W if blood
glucose is below 50mg/dL at 2cc/kg
 Monitor blood glucose as indicated
Temperature SGA.  Warm, humidified oxygen as soon as
premature, possible
asphyxiated  Warm objects before contact with
neonates, neonate
acutely ill,  Use radiant warmer or transport
open skin incubator if available
detects  Do not use air-conditioning whole on
(abdomen, transport
spine)  It better for the watchers to suffer
from heat, than the neonate from
hypothermia
Airway Premature,  Evaluate respiratory distress,
meconium  RR > 6O and <40bpm
aspiration  Respiratory effort (apnea,
syndrome, gasping, shallow or labored
asphyxiated breathing)
neonates,  Color (generalized cyanosis)
congenital  Strongly consider intubation on the ff:
anomaly like  Unable to ventilate and/or
TEF, CDH oxygenate with bag/mask
ventilation (BVM)
 Prolonged BVM is require
 Diaphragmatic hernia
 pCO2 is 55; especially if pH is <7.25
 labored breathing
 presence of pathologic apnea
 gasping respirations
Blood Hypovolemia  Evaluate systolic, diastolic and mean
pressure Heart failure blood pressure
Sepsis  Evaluate the pulse pressure by
NOTE: subtracting the diastolic from the
This may not systolic measurement (Normal: 25- 30
be most mmHg for term neonate while 15-
applicable 25mmHg for preterm)
to institutions  Evaluate peripheral pulses
in the NOTE: BP may he normal even if in shock
community (compensated shock).
 If shock is considered, IV push of
PNSS at 10cc/kg is warranted
Laboratory Infection  Review maternal and neonatal
works Bleed history for risk factors of infection
MAS  Check labs. CBC, Culture. X-ray.
pneumonia ABGs
Acidosis  Start Antibiotics promptly
NOTE: Infection in neonate may present
subtle signs and symptoms. CBC
maybe normal, but be suspicious.
Emotional  Facilitate maternal visit with neonate
support before transport
 Congratulate parents on birth of
child
 Call the baby by name if one has
been given and refer by correct
gender
 Identify support people like clergy,
family, friends
Neonatal Pneumonia
Definition:
Neonatal Pneumonia it an infection of the lungs
among children less than 2 months.
Sample Orders
 Please admit to SNU/N1CU
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC. Plt. blood typing. Blood C/S, RBS
 CXR AP/L
 IV:
 For 1day old neonate:
 D10 W500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10 IMB 500cc to run (100cc/kg/day)
 Meds:
 Ampicillin 100 mg/kg/day IVTT Q12 (for age ≤ 7
days) OR
 Gentamycin 5mg/kg/day IVTT OD OR
 Amikacin 15mg/kg/day IVTT OD
 O2 inhalation either nasal cannula at 3 I PM OR
facemask at 6 LPM (depending on respiratory
assessment)
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/Hepa B vaccines
 NB screening test
 ATS 1,500 units IM (if home delivered)
 Monitor O2 sat Q2hours & refer for < 95%
 Refer for cyanosis, seizure, and other untoward event
Nosocomial Pneumonia/ Infection

Definition:
Nosocomial pneumonia refers to any pulmonary
infection contracted by a patient in a hospital at least
48-72 after being admitted. It is usually caused by
bacteria, rather than a virus. It lengthens a hospital stay
by 1-2 weeks.
Risks:
 Exposure to instrumentation
 Mechanical ventilator
 Suctions
 IV sites
 Others
Sample Orders:
 Please admit to SNU
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 RBS
 Blood C/S
 IV: D5IMB 500cc to run (100cc/kg/day)
 Meds:
 Ceftazidime 100mg/kg/day IVTT Q6 ( ) ANST PLUS
 Amikacin 15mg/kg/day IVTT OD
 Paracetamol 12mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
 O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM (depending on respiratory effort)
 Place patient on moderate high back rest
 Monitor O2 sat Q2hours & refer for ≤ 95%
 Refer for cyanosis, progress of DOB, seizure or any
untoward events
Neonatal Sepsis
Definition:
Neonatal Sepsis is a clinical syndrome of systemic illness
accompanied by bacteremia occurring in the first
month of life.

Classification:
 Early-onset Sepsis (EOS)
 presents on the first 5-7 days of life
 usually multi-system and fulminant illness with
prominent respiratory symptoms
 associated with intrapartum and perinatal
complications
 Late-onset Sepsis (LOS)
 presents as early as 5 days of life
 usually insidious but it can be fulminant as well
 not associated with obstetric complications

Risk factors:
 Prematurity
 Rupture of membrane (more than 18 hours)
 Maternal peripartum fever or infection
 Resuscitation at birth
 Multiple gestation
 Invasive procedures

Clinical Manifestations:
 Temperature Instability
 Hypothermia- usually bacterial sepsis
 Hyperthermia- usually viral cause
 Change in behavior
 Poor activity
 Poor cry
 Lethargy
 Feeding problem
 Feeding intolerance, vomiting, diarrhea
 Abdominal distention with or without visible loops
 Skin
 Cyanosis, Mottling, Rashes, Sclerema, Jaundice
 Cardiopulmonary
 Tachypnea
 Respiratory distress (grunting, flaring etc...)
 Tachycardia
 Metabolic
 Hypoglycemia, Hyperglycemia, Acidosis

Sample Orders:
 Please admit to SNU/NICU
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, pit, blood typing
 RBS
 Na, K
 Blood CS
 CXR AP/L (as needed)
 IV:
 For 1 day old neonate:
 D10W 500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10IMB500cc to run (100cc/kg/day)
 Meds:
 Ampicillin 100 mg/kg/day IVTT Q12 (for age <7days)
OR Q6 (for age > 7days) PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 O2 inhalation either nasal cannula at 3 LPM OR
facemask at 6 LPM
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 ATS 1,500 units IM (if home delivered)
 Monitor O2 sat Q2hours & refer for < 95%
 Check hgt now then Q6 & refer for ≤40 or ≥140 mg/dL
 Refer for poor suck, cyanosis, DOB, seizure, and other
untoward events
Potentially Septic Newborn (PSNB)
Basis:
 Premature Rupture of Membrane (more than 18
hours)
 History of maternal fever or infection
 History of attempted home delivery
 Unsterile internal examination (usually by hilots)
 Otherwise the baby has good suck, cry and activity
Action:
 the neonate should be managed as Sepsis until
Blood C/S results will reveal no growth.
Sample Orders:
 Please admit to SNU/NICU
 Secure consent
 TPR Q2
 Start feeding Q2 as tolerated
 Labs:
 CBC, pit, blood typing
 RBS
 Blood C/S
 Insert IV and place on heplock
 Meds:
 Ampicillin 100 mg/kg/day IVTT 012 PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 ATS 1,500 units IM (if home delivered)
 Check hgt now then Q6 & refer for ≤ 40 or ≥140 mg/dL
 Refer for poor suck, cyanosis, DOB, seizure, and other
untoward events
Meconium Aspiration Syndrome (MAS)

Definition:
MAS is an obstruction of the airway with a meconium
which interferes with gas exchange and leads to acute
or chronic hypoxia and/or infection.
Pathophysiology:
 Airway Obstruction
 Big airway may cause atelectasis
 Small airway may lead to air trapping due to ball-
valve effect, and later result to air leak that causes
pneumothorax or pulmonary interstitial
emphysema.
 Chemical Pneumonitis
 Inactivation of existing sulfactant
Risk Factors:
 Post term pregnancy
 pre-eclampsia-eclampsia
 maternal hypertension
 maternal diabetes mellitus
 Oligohydramnios
Clinical Manifestations:
 meconium stained umbilicus and/or nail beds
 tachypnea
 difficulty of breathing
 nasal flare
 ± intercostal retraction
 cyanosis

Sample Orders:
 Please admit
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, plt, blood typing
 CXR AP/L (preferably 4 hours after)
 IV:
 For 1 day old neonate:
 D10W 500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10IMB 500cc to run (100cc/kg/day)
 Meds:
 Ampicillin 100 mg/kg/day IVTT Q12 PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM (depending on respiratory effort)
 if with minimal pneumothorax or
pneumomediastinum:
 may give Nitrogen wash by O2 hood at 10 LPM
 may do endotracheal intubation if needed
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 Monitor O2 sat Q2hours & refer for < 95%
 Refer for cyanosis, DOB, seizure, and other untoward
events
Neonatal Jaundice

Definition;
Neonatal Jaundice is a clinical condition by which
there is an increase m the total serum bilirubin resulting
from a high rate of bilirubin production compared to
that of elimination
Pathophysiology:
 Physiologic Jaundice
 Breast feeding and Jaundice
 Breast-feeding jaundice
 Breast milk jaundice
 Pathologic Jaundice with its common causes:
 ABO incompatibility
 Sepsis

Orders for pathologic jaundice:


 Please admit to SNU/NICU
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, plt, blood typing
 Maternal blood type
 B1B2
 Coomb’s test (jaundice within 12 hours)
 Blood CS
 IV:
 For 1 day old neonate:
 D10W 500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10IMB 500cc to run (100cc/kg/day)
 Meds:
 Ampicillin 100 mg/kg/day IVTT Q12 (for age <7days)
OR Q6 (for age > 7days) PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 Place under phototherapy with eyes and genitals
covered with sterile OS
 If level of Total Bilirubin is
 ≥ 20 for ABO incompatibility
 ≥ 25 for Sepsis
 ≥ 10 times the weight in premature
Order or refer for Double Volume Exchange Blood
Transfusion (DVET, see page 122)
 Refer for cyanosis, DOB, seizure, and other untoward
Omphalitis

Definition:
Omphalitis is characterized by erythema and/or
induration of the periumbilical area with purulent
discharge from the umbilical stump.

Sample Orders:
 Please admit to SNU
 Secure consent
 TPR Q2
 Encourage breastfeeding
 Labs:
 CBC, plt, blood typing
 RBS
 CXR AP/L (as needed)
 Blood C/S
 Gram stain of umbilical discharge
 IV: D5IMB 500cc to run (100cc/kg/day)
 Meds:
 Oxacillin 100mg/kg/day IVTT Q6
 May add:
 Gentamycin 5mg/kg/day IVTT OD OR
 Amikacin 15mg/kg/day IVTT OD
 Keep thermoregulated
 (If home delivered) Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 ATS 1,500 units IM
 Refer for cyanosis, DOB, seizure, and other untoward
Perinatal Asphyxia

Definition:
Perinatal Asphyxia is a condition caused by a lack of
oxygen in respired air, resulting in impending or actual
cessation of apparent life. It is a condition of impaired
blood gas exchange that, if it persists, leads to
progressive hypoxemia and hypercapnia with a
metabolic acidosis.

Mechanisms of Asphyxia:
 Interruption of the umbilical circulation (cord
compression)
 Inadequate perfusion of the maternal side of the
placenta (maternal hypotension, hypertension,
abnormal uterine contractions).
 Impaired maternal oxygenation (anemia)
 Altered placental gas exchange (previa)
 Failure of the neonate to accomplish lung inflation
Essential Characteristics based on joint definition of
American Academy of Pediatrics (AAP) and American
College of Obstetricians and Gynecologists (AOCG):
 Profound metabolic or mixed academia (pH <7.0)
on umbilical cord arterial blood sample;
 persistence of an APGAR score of 0-3 for >5min;
 neurologic manifestations in the immediate
neonatal period to include seizures, hypotonia,
coma and hypoxic-ischemic encephalopathy (HIE);
and
 evidence of multiorgan system dysfunction in the
immediate neonatal period to include shock,
hypotension, oliguria, NEC, ARDS,
thrombocytopenia, acidosis, hypoglycemia and
many more.

Sample Orders:
 Please admit
 Secure consent
 TPR Qhourly
 NPO
 Labs:
 CBC, plt, blood typing
 CXR AP/L
 Cranial X-ray and UTZ (if forceps delivery)
 ABG (if available)
 IV:
 For 1 day old neonate:
 D10W 500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10IMB 500cc to run (100cc/kg/day)
 If the patient is still on NPO, otherwise may shift
to D5IMB instead
 Meds:
 Ampicillin 100 mg/kg/day IVTT Q12 PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 May ADD:
 Citicoline 100mg/kg/day IVTT Q6,8,12
 For Seizure:
 Phenobarbital 10mg/kg slow IVTT, then repeat
another 10mg/kg slow IVTT 30mins after the first
dose, then give maintenance dose of 5
mg/kg/day Q12
 If intubated,
 may give diazepam 0.2mg/kg/dose slow IVTT for
frank seizure
 O2 inhalation facemask at 6 LPM; If with poor Apgar
Score with or without poor respiratory effort
 Intubate the patient and place on continuous
ambu-bagging or hook to mechanical ventilator
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 ATS 1,500 units IM (if home delivered)
 Monitor O2 sat Q2& refer for ≤ 95%
 1 & O monitoring and record quantitatively
 Refer for cyanosis, DOB, episodes of seizure, and other
untoward
Prematurity

Definition:
A preterm neonate is one whose birth occurs through
the end of the last day of the 37th week.
Risks:
 Low socioeconomic status
 Mother younger than 16 years or older than 35 yo.
 Maternal activity
 Maternal Illness
 Multiple-gestation births
 Prior poor birth outcome
 Obstetric factors
 Fetal condition
 Unintentional early delivery
Problems of prematurity
 Respiration
 RDS, Apnea, Brochopulmonary Dysplasia
 Neurologic
 Perinatal depression, Intracranial hemorrhage
 Cardiovascular
 Hypotension
 Hypovolemia, Cardiac dysfunction, Vasodilation
due to sepsis
 Hematologic
 Anemia, Hyperbilirubinemia.
 Gastrointestinal
 Necrotizing enterocolitis
 Temperature regulation
 Hypothermia or hyperthermia
 Immunologic
 Prone to infection due to deficiency in humeral
and cellular immune response
For ≥ 34 weeks AOG

Sample Orders for > 34 weeks AOG


 Please admit to SNU/NICU
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, plt, blood typing
 RBS
 CXR AP/L
 Na, K (for 1 day old up)
 Blood C/S (if with signs/symptoms of Sepsis)
 ABG (if with respiratory distress)
 IV:
 For 1 day old neonate:
 D10W 500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10IMB 500cc to run (100cc/kg/day)
 Meds: (if needed)
 Ampicillin 100 mg/kg/day IVTT Q12 (for age <7days)
OR Q6 (for age > 7days) PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 Monitor O2 sat Q2& refer for ≤ 95%
 Refer for cyanosis, DOB, seizure, and other untoward
For < 34 weeks AOG

Sample Orders for neonate < 34 weeks AOG


 Please admit to SNU/NICU
 Secure consent
 TPR Q2
 NPO
 Labs:
 CBC, plt, blood typing
 RBS
 Na, K
 CXR AP/L
 Blood C/S (if with signs/symptoms of Sepsis)
 ABG (if with respiratory distress)
 IV :
 For 1 day old neonate:
 D10W 500cc to run (80cc/kg/day)
 For 2 days old neonate onwards:
 D10IMB 500cc to run (100cc/kg/day)
 Meds: (if needed)
 Ampicillin 100 mg/kg/day IVTT Q12 PLUS
 Gentamycin 5 mg/kg/day IVTT OD OR
 Amikacin 15 mg/kg/day IVTT OD
 If with apnea of prematurity
 start Aminophylline 6mg/kg/dose slow IVTT as LD,
then maintain on 3mg/kg/d Q6
 O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 Monitor O2 sat Q2& refer for ≤ 95%
Necrotizing Enterocolitis (NEC)

Definition:
NEC is an acquired neonatal disorder representing an
end expression of serious intestinal injury after a
combination of vascular, mucosal, and metabolic
insults to a relatively immature gut (Gomela).
Risk Factors:
 Prematurity
 Asphyxia
 Enteral Feeding
 Polycythemia and hyperviscosity syndromes
 Exchange Transfusion
 Feeding volumes
 Enteric Pathogenic microorganism
Clinical Manifestations according to Stage:
 Stage I: Suspected NEC
 Systemic signs are nonspecific, including apnea,
bradycardia, lethargy, and temperature instability.
 Intestinal findings include feeding intolerance,
recurrent gastric residuals, and guaiac-positive
stools.
 Radiologic findings are normal or nonspecific.
 Stage IIA: Mild NEC
 Systemic signs are similar to those in Stage I.
 Intestinal findings include prominent abdominal
distention with or without tenderness, absent bowel
sounds, and gross blood in the stools.
 Radiographic findings include ileus, with dilated
loops with focal areas of pneumatosis intestinalis.
 Stage IIB: Moderate NEC
 Systemic signs include Stage I signs plus mild acidosis
and thrombocytopenia.
 Intestinal findings include increasing distention,
abdominal wall edema and tenderness with or
without a palpable mass.
 Radiographic findings include extensive
pneumatosis and early ascites.
 Stage IIIA: Advanced NEC
 Systemic signs include respiratory and metabolic
acidosis, assisted ventilation for apnea, decrease
blood pressure and urine output, neutropenia, and
coagulopathy.
 Intestinal findings include spreading edema,
erythema or discoloration and induration of the
abdominal wall.
 Radiographic findings include prominent ascites,
paucity of bowel gas, and possibly a persistent
sentinel loop.
 Stage MB: Advanced NEC
 Systemic findings reveal generalized edema,
deteriorating vital signs and laboratory indices,
refractory hypotension, shock syndrome, DIC and
electrolyte imbalance.
 Intestinal findings reveal a tense, discolored
abdomen and ascites
 Radiographic findings commonly show absent
bowel gas and often evidence of intraperitoneal
free air.

Advice:
NEC that may be admitted in rural setting is Stage I:
Suspected NEC. Other stages should be referred to
tertiary care.

Sample Orders: NEC Suspect:


 Please admit
 Secure consent
 TPR Q2
 NPO x 3 days
 Labs:
 CBC, plt, blood typing
 RBS
 Na, K
 Flat plate abdomen
 Blood C/S (if with signs/symptoms of Sepsis)
 IV: D10 IMB 500cc to run (120cc/kg/day) – may
consider to add Ca gluconate at 200 – 300 mg/kg/day
 Meds:
 Metronidazole 7.5-15mg/kg/day IVTT 012 PLUS
 Ampicillin 100mg/kg/day IVTT Q12 (for age <7days)
or Q6 (for age > 7days) PLUS
 Gentamycin 5mg/kg/day IVTT OD OR
 Amikacin 15mg/kg/day IVTT OD
 Ranitidine 2mg/kg/day IVTT Q8 (If with signs of GI
bleed)
 Keep thermoregulated
 Routine NB care (If home delivered)
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG/ Hepa B vaccines
 NB screening test
 ATS 1,500 units IM
 OGT insertion and aspirate as frequent as needed for
bowel decompression
 Check hgt now then Q6 & refer for ≤ 40 or ≥ 140 mg/dL
 Refer for poor suck, cyanosis, DOB, seizure, and other
untoward events

NOTE:
 Dopamine may be started at 5 ug/kg/min for
improvement of G.I. and renal perfusion.

Neonate Hematocrit ≥ 0.65


 Hydrate patient for 8 hours, then request for central
hematocrit
 Use D5LR for hydration more than 120cc/kg/day
 Regulate TFR to full maintenance for age after
extraction of central hematocrit
 For age within 24 hours old = 100cc/kg/day in 8
hours

 Indication for Partial Exchange Transfusion (PET)


 If central hematocrit is still ≥ 0.65 despite of hydration
 If central hematocrit is still ≥ 0.65 and with age more
than 24 hours with or without hydration
Well Baby
Well Baby, Term, AGA, NSVD
Bases:
 No maternal set-up
 APGAR = 7 to 9
 Good suck, cry and activity

 Keep dry & thermoregulated


 Room in and do not separate from the mother
 Encourage breastfeeding as tolerated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG & Hepa B vaccines
 NB screening test
 Monitor baby’s suck, cry and activity

Well Baby, Term, AGA, Cesarean Section


Bases
 No maternal set-up
 APGAR = 7 to 9
 Good suck, cry and activity

 Keep dry & thermoregulated


 Room in and do not separate from the mother
 Encourage breastfeeding as tolerated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG & Hepa B vaccines
 NB screening test
 Monitor baby’s suck, cry and activity
Well Baby, Term, SGA (>2kg) or LGA (>3.7kg)
Bases
 Unknown maternal set-up
 APGAR = 7 to 9
 Good suck, cry and activity
 SGA or LGA by Ballard Score

Risks
 Hyperglycemia or hypoglycemia
 Polycythemia

 Keep dry & thermoregulated


 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG & Hepa B vaccines
 NB screening test
 LABS:
 CBC plt, Blood typing
 RBS, Hgt
 Room in and do not separate from the mother
 Encourage breastfeeding as tolerated once
hematocrit ≤ 0.65
 Monitor baby’s suck, cry and activity
Well Baby, Term, SGA (<2kg)
 Please admit
 Secure consent
 TPR q2
 LABS:
 CBC plt, Blood typing
 RBS
 Hgt/RBS
 IVF: D10W 500cc to run (80cc/kg/day)
 Keep thermoregulated
 Routine NB care
 Vitamin K 1mg SQ
 Cord care
 Erythromycin eye ointment OU
 BCG & Hepa B vaccines
 NB screening test
 Encourage breastfeeding as tolerated once
hematocrit ≤ 0.65
 For observation x 24 hours
Neurology
Doctors’ Guide
CNS Infections

Definition of Terms:
 Meningitis refers to inflammation of the
leptomeninges, the connective tissue layer in close
proximity to the surface of the brain.
 Encephalitis refers to inflammation of brain
parenchyma.
 Meningoencephalitis is the involvement of structures
affected in meningitis and encephalitis.
Etiology:
 Suppurative/Bacterial Meningitis:
 0-2 months:
 E. coli; gram (-) bacilli; S. pneumoniae
 2mons-5years:
 H. Influenza; S. Pneumoniae; N. Meningitides
 > 5 years old:
 S. Pneumoniae; N. Meningitides
 TB Meningitis:
 Mycobacteria Tuberculosis
 Viral Meningitis:
 Enterovirus
 Encephalitis:
 Secondary (Para infectious or Post infection)
Encephalitis:
 Measles, Varicella, Rubella
 Slow Viral Infections:
 SSPE (Subacute Slerosing Panencephalitis)
 Progressive Rubella Panencephalitis
 • Virus:
 Herpes simplex (all ages)
 Enteroviruses (infants and children)
 Rabies (infants and children)
 Varicella (all ages)
 Brain Abscess
 Streptococcus, Bacteroides fragilis, S. Aureus
Clinical Manifestation of CNS infection
Signs and Older infants and
Neonates
Symptoms children
Fever or Fever
hypothermia Anorexia
Abnormally sleepy Confusion
or Lethargic Irritability
Refuse or poor Photophobia
Nonspecific
feeding Nausea
Cyanosis Vomiting
Grunting Headache
Apneic episodes Seizure
Vomiting
(+) or (-) neck Neck rigidity
Meningeal
rigidity Kemig’s sign
inflammation
Brudzinski sign
Bulging fontanel Headache
Diastasis of sutures Bulging fontanel
Convulsions Diastasis of
Opisthotonus sutures
Increase ICP (infants)
Papilledema
Mental confusion
Altered state of
consciousness
Hemisparesis Hemisparesis
Ptosis Ptosis
Focal neurologic
Facial nerve palsy Deafness
signs
Optic neuritis
Facial nerve palsy
CSF Difference in CNS Infection:
Opening
Glucose Protein
CSF Findings pressure Cell count
(mg/dL) (mg/dL)
(mmH2O)
50 – 75% (at
least 50% of
Normal 90 – 180 0 – 5 lymphocytes 15 – 40
simultaneous
serum glucose)
100 – 5,000
Bacterial
200 – 300 neutrophils, usually Reduced. <40 100 – 1,000
Meningitis
>80%
100 – 200,
but upto
TB Usually <500
180 – 300 Reduced. <40 1,000 if
Meningitis lymphocytes
CSF block
is present
10 – 300 lymphocytes;
Normal
may be >1,000 in
occasionally
Viral echovirus and mumps
90 - 200 slightly reduced 50 - 100
Meningitis meningitis with upto
in mumps
80% neutrophilic
meningitis
predominance
Viral
180 – 300 0 – 500 lymphocytes Normal 50 - 100
Encephalitis

Contraindication of Lumbar Tap:


 Absolute:
 skin infection on puncture site
 Relative:
 increase ICP with papilledema
 localization (anisocoria, one sided neurologic
findings)
 suspected intracranial mass (space occupying
lesion)
 hematologic problems (eg. platelet of < 100,000)
 significant cardiopulmonary compromise and shock
Suppurative/Bacterial Meningitis

Sample Orders:
 Please admit
 Secure consent
 TPR Q2 to include BP monitoring
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 Serum Na, K
 CSF analysis (review previous page for
contraindications)
 IVF: D5LR at full maintenance rate
 Meds
 For 0-2 months:
 Ampicillin 300mg/kg/day IVTT Q12 (for age
<7days) or Q6 (for age > 7days) PLUS
 Gentamycin 5mg/kg/day IVTT OD OR
 Amikacin 15mg/kg/day IVTT OD OR
 Cefotaxime 200mg/kg/day IVTT Q12 (for age
<7days) or Q6 (for age > 7days)
 For 2months to 5 years old:
 Chloramphenicol 100mg/kg/day IVTT Q6 AND/OR
 Penicillin G 300,000 Units as drip Q6 ( )ANST OR
 Ampicillin 300mg/kg/day IVTT Q6 ( ) ANST OR
 Ceftriaxone 100mg/kg/day IVTT OD OR Q12
( ) ANST
 More than 5 years old
 Penicillin G 300,000 Units as drip Q6 ( )ANST
AND/OR
 Chloramphenicol 100mg/kg/day IVTT Q6 OR
 Ceftriaxone 100mg/kg/day IVTT Q12 ( ) ANST OR
 Cefotaxime 200mg/kg/day IVTT Q6 ( ) ANST
 For increase ICP (decompression):
 Mannitol 5cc/kg as IV bolus, then Q4 (BP should be
at normal for age before administration of this
meds) OR
 Sodium Lactate (Totilac) 5cc/kg as LD, then 1cc/kg
Qhourly
 For Seizure:
 Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
 Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12 (is usually started if
patient has a history of more than 1 seizure
episodes)
 Paracetamol 10mg/kg/dose Q4 PRN for temp ≥
38°C
 Secure consent for lumbar tap procedure (hold the
procedure if with contraindications).
 I & O monitoring and record quantitatively
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q2 to include O2 saturation
 Refer for cyanosis, DOB, seizure, apnea or any
untoward events

Recommended Number of Days of Treatment according


to etiology:
 H. Influenza : 7-10 days
 S. Pneumoniae : 10-14 days
 N. Meningitides : 7 days
 Group B Strep : 14-21 days
 Aerobic gram (-) bacilli : 21 days
 Listeria Monocytogenes : > 21 days
TB Meningitis

Important consideration for patients with history of TB or


exposure to active TB patients.

Clinical Features by Staging of symptoms:


 Stage I (typically lasts 1— 2 wk)
 Nonspecific symptoms (fever, headache, irritability,
drowsiness, and malaise)
 Focal neurologic signs are absent, but infants may
experience a stagnation or loss of developmental
milestones.
 Stage II (usually begins more abruptly)
 Nuchal rigidity, seizures, positive Kemig or Brudzinski
signs, hypertonia, vomiting, cranial nerve palsies,
and other focal neurologic signs.
 Development of hydrocephalus, increased
intracranial pressure, and vasculitis.
 Stage III
 Coma, hemiplegia or paraplegia, hypertension,
decelerate posturing, deterioration of vital signs, and
eventually death.

Sample Orders:
 Please admit
 Secure consent
 TPR Q2 to include BP & O2 saturation monitoring
 NPO except oral meds by OGT
 Labs:
 CBC, plt
 CXRAP/L
 Serum Na, K
 CSF analysis (review contraindications)
 PPD or sputum examination (if applicable)
 IVF: D5LR at full maintenance rate
 Meds:
 Anti-TB meds (first l-2months)
 Isoniazid 10-15 mg/kg/day PO(max : 300mg/D)
PLUS
 Rifampicin 10-20 mg/kg/day PO (max : 600mg/D)
PLUS
 Pyrazinamide 10-40 mg/kg/day PO (max : 2g/D)
PLUS
 Streptomycin 20-40 mg/kg/day IM (max : 1g/D) OR
 Ethambutol 15-20 mg/kg/day PO (requires visual
monitoring)
 Anti-TB (for the next 9-12 months)
 Isoniazid 10-15 mg/kg/day PO(max : 300mg/D)
PLUS
 Rifampicin 10-20 mg/kg/day PO (max : 600mg/D)
 For increase ICP (decompression):
 Mannitol 5cc/kg as IV bolus, then Q4 (BP should be
at normal for age before administration of this
meds) OR
 Sodium Lactate (Totilac) 5cc/kg as LD, then 1cc/kg
Qhourly
 For Seizure:
 Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
 Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/dayQ12 (is usually started if
patient has a history of more than 1 seizure
episodes)
 Paracetamol 10mg/kg/dose Q4 PRN for temp ≥ 38°C
 Secure consent for lumbar tap procedure (hold the
procedure if signs of increase ICP are NOTEd.
 Refer to surgery for evaluation and management (if
the patient has evidence of obstructive hydrocephalus
and neurological deterioration)
 I & O monitoring and record quantitatively
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Refer for cyanosis, DOB, seizure, apnea or any
untoward events

NOTE:
 For Stage II and Stage III, some pediatricians practice
and suggest the use of:
 Prednisone l -2mg/kg for 6-8 weeks with tapering of
dosage on the 2nd half of the course.
 Dexamethasone 6mg/m2 Q4 or Q6 for consistent
elevation of ICP to reduce edema.
Viral Meningitis

Important information:
 higher incidence during summer to fall months
 no specific antiviral therapy
 treatment is supportive with IV fluids
 outcome is usually a full recovery

Sample Orders:
 Please admit to Ward
 Secure consent
 TPR Q2 to include BP monitoring
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 Serum Na, K
 CSF analysis (review contraindications for LP)
 IVF: D5LR at full maintenance rate
 Meds:
 Acyclovir 10 mg/kg IV infusion Q8 for at least 10days
 For Seizure:
 Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
 Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/dayQ12 (is usually started if
patient has a history of more than 1 seizure
episodes)
 Paracetamol 10mg/kg/dose Q4 PRN for temp ≥ 38°C
 Secure consent for lumbar tap procedure (hold the
procedure if signs of increase ICP are NOTEd)
 I & O monitoring and record quantitatively
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q2 to include O2 saturation
 Refer for cyanosis, DOB, seizure, apnea or any
untoward events
Brain Abscess

Mechanisms:
 Direct extension of contiguous infection
 Penetrating head injuries
 Hematogenous spread

Sample Orders:
 Please admit
 Secure consent
 TPR Q2 to include BP monitoring
 NPO
 Labs:
 CBC, plt
 CXR AP/L
 Serum Na, K
 Cranial CT scan
 IVF: D5LR at full maintenance rate
 Meds:
 Penicillin G 300,000/kg/day Units as drip Q6 ( )ANST
(for streptococci coverage) PLUS
 Metronidazole 30mg/kg/day IVTT Q8 (for
Bacteroides fragilis coverage) PLUS
 Oxacillin 200mg/kg/day IVTT Q6 ( )ANST (for
staphylococcus aureus coverage)
 For Seizure:
 Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
 Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12 (is usually started if
patient has a history of more than 1 seizure
episodes)
 Paracetamol 10mg/kg/dose Q4 PRN for temp ≥ 38°C
 Secure consent for lumbar tap procedure (hold the
procedure if signs of increase ICP are NOTEd).
 Refer to surgery for evaluation and management
 I & O monitoring and record quantitatively
 O2 inhalation via facemask at 6 LPM
 Place patient on moderate high back rest
 Monitor V/S Q2 to include O2 saturation
 Refer for cyanosis, seizure, or any untoward events
Febrile Seizures

Definition:
Febrile Seizures are seizures in 3 months to 6 years old
children associated with fever in the absence of CNS
infection, acute electrolyte imbalance or history of
afebrile seizures in a young child.
Types of Febrile Seizures:
 Simple
 characterized as brief (<15mins), generalized
(usually tonic-clonic) and a single event in 24 hours
of the same febrile illness.
 1 to 1.5% develops epilepsy
 Complex
 characterized as prolonged (>10-15mins), focal
seizures and recurrent within 24 hours of the same
febrile illness.
 4 to 15% develops epilepsy
 Febrile Myoclonus
 seizure type is myoclonus
 Febrile Status Epilepticus
 duration of seizure is > 30mins
Risk factors for recurrent Febrile Seizures:
 Family history of febrile seizures
 Shorter duration of fever (about 1hr) before seizure
 Ages < 19 mos of first febrile seizure
 Low temperature (close to 39°C triggering seizure
Risk factors for Epilepsy:
 Family history of epilepsy
 Short duration of fever (about 1hour) before seizure
 Complex febrile seizures
Sample Orders:
 Please admit
 Secure consent
 TPR Q2
 NPO temporarily
 Labs:
 CBC, plt
 Urinalysis
 CXR AP/L
 CSF Analysis (for ages 18 months below or with signs
of CNS infection)
 Na, K, Mg, Ca, RBS (if applicable)
 IV: D5LR or D5IMB at full maintenance rate
 Meds:
 Paracetamol 10-15mg/kg/dose Q4 IVTT RTC for temp
≥ 38°C
 For Seizure:
 Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
 Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12 (For Complex Febrile
Seizure)
 O2 inhalation via facemask at 6 LPM
 Secure consent for lumbar tap procedure (to rule out
CNS infection)
 Place patient on moderate high back rest
 Monitor V/S Q2 to include O2 saturation
 Refer for cyanosis, progress of DOB, Seizure or any
untoward events

NOTE:
 The focus of infection should be worked up. If
coverage is needed, appropriate antibiotics may be
started.
Algorithm: Evaluation and Management of a Child with a
First Simple Febrile Seizure
Acute Symptomatic Seizure (ASS)

Definition:
ASS occurs only in association with precipitants or
triggered factors. This is also known as Situation-related
seizures.
Precipitating factors:
 Fever in young children
 Sleep deprivation
 Hypertension
 Metabolic imbalance
 Alcohol or drug abuse
 Acute head trauma
 CNS infection

Sample Orders:
 Please admit
 Secure consent
 NPO temporarily
 Labs:
 CBC, plt
 Urinalysis
 CXR AP/L
 CSF Analysis (review contraindications)
 Na, K, Mg, Ca, RBS
 IV: D5LR or D5IMB at full maintenance rate
 Meds:
 Find and treat the focus causing the seizure
 For Seizure:
 Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
 Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12
 May start antibiotics for meningitis if on admission,
CNS infection is highly considered
 Paracetamol 10-15mg/kg/dose Q4 IVTT RTC for temp
≥ 38°C
 O2 inhalation via facemask at 6 LPM
 Secure consent for lumbar tap procedure (to rule out
CNS infection)
 Place patient on moderate high back rest
 Monitor V/S Q2 to include O2 saturation
Refer for cyanosis, DOB, seizure or any untoward events
Hematology
Doctors’ Guide
Anemia

Definition:
Anemia is a reduction of the RBC volume or
hemoglobin concentration below the range of values
occurring in healthy persons (Nelsons)
Complete History includes but not limited to:
 blood loss
 fatigue
 pica
 medication exposure
 growth and development
 nutritional history
 menstrual history
 ethnic background
 history of hyperbilirubinemia
 family history of anemia, splenectomy, or
cholecystectomy
Physical Examination
 pallor
 jaundice
 glossitis
 tachypnea
 tachycardia
 cardiac murmur
 hepatosplenomegaly
 signs for systemic illness
Causes of Anemia
 Problems in production
 Factory problem (eg. aplastic anemia,
thalassemia)
 Raw materials problem (eg. Folic acid deficiency,
Vitamin B12 deficiency)
 Problems in destruction (eg. malaria, sickle cell
anemia)
 Blood Loss (eg. occult blood loss 2° to typhoid fever,
trauma, APCD)
Classification through Peripheral Blood Smear (PBS):
 Microcytic anemia
 Macrocytic anemia
 Normocytic anemia
Differential Diagnoses based on PBS and Reticulocyte
count:
Retic Microcytic Normocytic Macrocytic
Count anemia anemia anemia
Folic acid
Chronic disease deficiency
Iron deficiency
Malignancy Vit B12
Lead poisoning
Renal failure deficiency
Low Chronic disease
Juvenile Aplastic anemia
Protein
Rheumatoid Drug-induced
malnutrition
arthritis Trisomy 21
Hypothyroidism
Thalassemia
Acute blood
trait
Normal loss
Sideroblastic
Hypersplenism
anemia
Thalassemia G6PD
High Active hemolysis
syndrome Hypersplenism

Sample Orders for Anemia with unknown etiology:


 Please admit
 Secure consent
 TPR Q4
 Diet:
 DAT or
 NPO (if with high output failure)
 Labs:
 CBC, platelet, blood typing
 RBC indices
 Reticulocyte count
 Peripheral smear
 Stool examination
 Urinalysis
 Serum bilirubin
 PT, PTT (if with bleeding)
 CXR AP/L (if with high output failure)
 IV: D50.3% NaCl at full maintenance rate
 Start SD: Dobutamine at 8ugms/kg/min (if with high
output failure)
 Meds:
 Treat concomitant infection if present
 Start appropriate antibiotics
 Paracetamol 12mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
 O2 face mask at 6LPM
 High back rest (if with high output failure)
 Secure PRBC of patient blood type, properly screened
and crossmatched, then transfuse 10-15cc/kg in 4
hours
 Give furosemide 0.5mg/kg/dose mid and post blood
transfusion
 (may repeat blood transfusion 12 hours after the
previous BT)
 Please repeat CBC 4-6 hours post blood transfusion
 Refer for transfusion reaction like allergy, cyanosis,
DOB, seizure or any untoward events

NOTE:
Some signs of high output failure in anemic patients
are diaphoresis, tachypnea, tachycardia, hemic or
gallop murmur, cardiomegaly, hepatomegaly.
Thalassemia/ Thalassemia Syndrome for Blood
transfusion

Information included in the History:


 When was the patient diagnosed with thalassemia?
 Last date of blood transfusion
 Units of blood usually consumed per transfusion
session
 Last date of chelation therapy
What to monitor at what particular admissions?
 Monthly:
 measure the pretransfusion hemoglobin
 Every 3 months:
 measure height and weight
 Every 6 months:
 measure ferritin
 complete blood chemistry,
 including liver function tests
 Every year:
 Evaluate growth and development
 Evaluate iron balance
 Complete evaluation of:
 Cardiac function: ECG, 2 D-Echo
 Endocrine function
 Visual and auditory acuity
 Viral serologies
 Bone densitometry
 Ongoing psychosocial support

Sample Orders:
 Please admit to Ward
 Secure consent
 TPR Q4
 DAT (low iron diet)
 Labs:
 CBC, plt, blood typing
 CXR AP/L (if needed)
 IV: PNSS 1L at maintenance rate
 Meds:
 Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥38°C
 Secure PRBC of patient blood type, properly screened
and crossmatched, then transfuse 10-15cc/kg in 4
hours
 Give furosemide 0.5mg/kg/dose mid and post blood
transfusion
 (may repeat blood transfusion 12 hours after the
previous BT)
 Please repeat CBC 4-6 hours post blood transfusion
 Place patient on moderate high back rest
 Refer for transfusion reaction like allergy, cyanosis,
DOB, seizure or any untoward events
ORTHOPEDICS NOTES
Doctors’ Guide
Adult < 40 years old

Sample orders
 Please admit patient
 Secure consent
 DAT/NPO
 Monitor V/S q4hrs
 Monitor I & O q4hrs
 Start IVF of D5LR 1L to run at KVO OR 20gtts/min
 If patient is Diabetic use PLR
 Diagnostics
 X-ray of affected extremity
 CBC plt, Blood typing
 Meds
 Ketorolac 30mg IVTT now then q8hrs ( ) ANST; PRN for
pain
 For severe pain
 Tramadol 50mg IVTT now then q6hrs, hold if BP
<90/60mmHg
 For Open Fracture
 Cefazolin 1gm IVTT now then q8hrs ( ) ANST
 ATS 3,000 IU IM at left deltoid ( ) ANST
 TT 0.5ml IM at right deltoid (if TT given more than
2yrs or when wound is dirty)
 If febrile
 Paracetamol 300mg IVTT now then q4hr, PRN for
fever ≥ 38ºC
 Immobilize affected extremity
 Watch out for excessive bleeding
 Do daily wound dressing
 Refer

X-ray to order guide Casting Materials to order


 AP/L for fracture of femur, tibia,  Wadding sheet
humerus, and other long bones  Plaster of Paris
 AP/O for fracture of hand and  Elastic bandage
feet  Arm sling (if upper extremity)
Adult ≥ 40 years old

Sample orders
 Please admit patient
 Secure consent
 DAT/NPO
 Monitor V/S q4hrs
 Monitor I & O q4hrs
 Start IVF of D5LR 1L to run at KVO OR 20gtts/min
 If patient is Diabetic use PLR
 Diagnostics
 X-ray of affected extremity
 CBC plt, Blood typing
 ECG 12L
 CXR PA upright
 Serum Crea
 U/A
 Meds
 Ketorolac 30mg IVTT now then q8hrs ( ) ANST; PRN for
pain
 For severe pain
 Tramadol 50mg IVTT now then q6hrs, hold if BP
<90/60mmHg
 For Open Fracture
 Cefazolin 1gm IVTT now then q8hrs ( ) ANST
 ATS 3,000 IU IM at left deltoid ( ) ANST
 TT 0.5ml IM at right deltoid (if TT given more than
2yrs or when wound is dirty)
 If febrile
 Paracetamol 300mg IVTT now then q4hr, PRN for
fever ≥ 38ºC
 For CP eval
 Immobilize affected extremity
 Watch out for excessive bleeding
 Do daily wound dressing
 Refer
Pediatrics

Sample orders
 Please admit patient
 Secure consent
 DAT/NPO
 Monitor V/S q4hrs
 Monitor I & O q4hrs
 Start IVF of D5LR 1L to run at KVO
 Diagnostics
 X-ray of affected extremity
 CBC plt, Blood typing
 CXR APL
 Meds
 Ketorolac 15mg IVTT now then q8hrs ( ) ANST; PRN for
pain
 For severe pain
 Tramadol 50mg IVTT now then q6hrs, hold if BP
<90/60mmHg
 For Open Fracture
 Cefazolin 500gm IVTT now then q8hrs ( ) ANST
 ATS 1,500 IU IM at left deltoid ( ) ANST
 TT 0.5ml IM at right deltoid (if patient is >7yo or TT
given more than 2yrs or when wound is dirty)
 If febrile
 Paracetamol 150mg IVTT now then q4hr, PRN for
fever ≥ 38ºC
 For Peida eval
 Immobilize affected extremity
 Watch out for excessive bleeding
 Do daily wound dressing
 Refer
MEDICATION
Doctors’ Guide
Computation of Drugs as Drip (Pedia)

STEP 1: Know the drugs commonly used as drips in pediatric


management, their available preparation and their
recommended dosage.
Drug Preparation Recommended Doses
Dopamine 40, 80, 160 mg/ml 2-20 mcg/kg/min

NOTE: commonly For Renal, mesenteric


available vasodilation
preparation is <5ugm/kg/min
40mg/ml
For Dopaminergic effect
& β receptor
activation
5-10ugm/min)

For β adrenergic effect


prominent vasocons
10-20ugm/min

For α adrenergic effect &


vasoconstriction
>20ugm/min
Dobutamine 12.5 mg/ml 2-20 mcg/kg/min
Epinephrine 1mg/ml 0.1-1 mcg/kg/min
Midazolam 5mg/ml 1-3 mcg/kg/min
Terbutaline 1mg/ml 0.1-0.4 mcg/kg/min
Lidocaine 10mg/ml/l% solution 20-50 mcg/kg/min

STEP 2: Use this formula for drip computation

)
)
)

NOTE: Let us put a constant unit for the desired rate in this
formula. (Our Constant is 10 ml/hr)
From: The Harriet Lane Handbook
Example: We want to start Dopamine drip to our
patient:

Available Preparation : 40mg/ml


Desired Dose : 8 mcg/kg/min
Weight of patient : 12 kg

STEP 3: Convert 57.6mg to ―cc‖ to run in 10 hours

STEP 4: Convert 1.44cc/10hours to ―cc/8hours‖ or ―cc/shift‖

STEP 5: Apply the result of this computation into specific


order for nurses to follow

Example Order:
 Please start Dopamine drip as follows:
 D5 Water = 38.8 cc
 Dopamine (8) = 1.2 cc
40 cc/shift or at 5ugtts/min

STEP 6: Since patient has on-going IV line, and Dopamine


drip is administered as side drip, revision of IV rate of
the mainline is needed.

Example: the mainline is running at 45ugtts/min, the order is


revised as follows:
Orders:
 Please reduce mainline IV rate to 40ugtts/min once
dopamine drip is already started.

Shortcut computation for:


 Dopamine in 40mg/ml

Example computation using same data as above

 Dobutamine in 12.5mg/ml

)
Preparation for Desired Dextrocity

The simplest way to prepare the desired dextrosity is by


following the recommendation below:

Conversion of D5 to:
 D7.5 = mix 475ml of D5 with 25ml of D50-50
 D10 = mix 450ml of D5 with 50ml of D50-50
 D12.5 = mix 425ml of D5 with 75ml of D50-50
All about Drips (Adult)

How to use the listed drip rates and equivalent


dosages given:
For example, the statement under number one for the
dapamine drip sees, ―Drip of 2.5-10mcg/kg/min is
equivalent to 9-38 ugtts/min for a 50 kg patient.‖ This
means that a dopamine drip of 2.5 mcg/kg/min is
equivalent to giving 9 ugtts/min for a 50 kg patient
while a dopamine drip of 10 mcg/kg/min is equivalent
to 38 ugtts/min for a 50 kg patient. Using similar
statements below as your guide, no tedious
computations maybe necessary for the average
patient.

1. Aminophylline Drip: D5W. 250 ml + Aminophylline


250 mg/amp at 15-40 ugtts/min
Maintenance Drip of 0.4-0.8 kg/kg/hr is equivalent
to 20-40 ugtts/min for a 50 kg patient.
Formula: ugtts/min= dose x BW
LD: 5 mg/kg BW in 30 ml D5W in a soluset (if patient
is not maintained on oral theophylline)
NOTE: Maintenance infusion rate must be reduced
to 0.2-0.3 mg/kg/hr for elderly patients, pregnant
patients and those with CHF, liver disease or cor
pulmonale

2. Amiodarone (Cordarone) Drip:


Preparation: 150 mg/3 ml vial
IV Loading Dose: 5-10 mg/kg/24 hour or 500-1000
mg in 24 hours. Intravenous loading doses were
given for an average of 4 days in clinical trials.
Estimated maximum daily dose of 1000 mg/24
hours for Filipinos.
Orders: Give 150 mg slow IV push over 10-30
minutes (with BP and HR monitoring) followed by
D5W 250 ml + 150 mg-300 mg IV Amiodarone to
run for 24 hours. Supplemental doses of 150 mg IV
over 10-30 mins may be given for recurrent
arrhythmias especially during the early phases of
dosing. No more than six additional boluses in any
24 hour period may be given.

OR

a. Oral loading dose: 10 kg/kg/day for two weeks


e.g. Amiodarone 200 mg 1 tab PO TID for 14 days.
Then maintenance of 200 mg 1 tab OD thereafter.

3. Clonidine (Catapres) Drip:


Concentration: 150 ug/ml ampule
D5W 250 ml + Clonidine 2 amps (150 mg/amp) at
5-30 ugtts/min

4. Clonidine/Hydralazine (Catapres/Apresoline) Drip:


D5W 250 ml+ Hydralazine 2 amps (20 mg/amp) +
Clonidine 2 amps (150 mg/amp) at 5-30 ugtts/min
(Up to 60 ugtts/min)

5. Diazepam (Valium) Drip:


D5W 100 ml + Diazepam 10 mg q 6 hours
(maximum: 60 mg/day)

6. Dobutamine Drip: D5W 250 ml + Dobutamine 250


mg/amp at 10-60 ugtts/min
Drip of 2.5-20 mcg/kg/min is equivalent to 80-60
ugtts/min for a 50 kg patient.
Formula: ugtts/min = (drip mcg x BW)/16.6
If with CHF, may use double dose: D5W 250 ml+
Dobutamine 500 mg (2 amps) at maximum rate of
30 ugtts/min
7. Dopamine Drip: D5W 250 ml+ Dopamine 200
mg/amp at 7-60 ugtts/min
Drip of 2.5-10 mcg/kg/min is equivalent to 9-38
ugtts/min for a 50 kg patient.
Formula: ugtts/min = (drip mcg x BW)/13.3
If with congestive heart failure (CHF), may use
double dose: D5W 250 ml + Dopamine 400 mg (2
amps) at maximum rate of 30 ugtts/min

8. Dopamine-Lasix Drip:
75 ml of Dopamine Pre-mix (D5W 250 ml+
Dopamine 200 mg) + 25 ml of Lasix 250 mg in a
soluset (Total of 100 ml) to run at 6-8 ugtts/min

9. Epinephrine Drip: D5W 250 ml + 1 amp (1 mg)


Epinephrine at 15-150 ugtts/min
Drip of 1-10 mcg/min is equivalent to 15-150
ugtts/min

10. Esmolol (Brevibloc) drip:


Preparation: 100 mg/10 ml vial
Concentration: 10 mg/ml
Loading dose: 0.5 mg or 500 mcg/kg/min
e.g.: 50 kg = 25 mg or 2.5 ml slow IV in > 1 minute
Maintenance dose: 25-200 mcg/kg/min; start at 50
mcg/kg/min over 4 min
e.g.: 50 kg =2.5 mg/min or 150 mg/hr or 15 ml/hr =
l5 ugtts/min

11. Furosemide (Lasix) Drip:


D5W 250 ml + Furosemide high dose 250 mg/amp
at 5-30 ugtts/min
Concentration: 1 mg/ml
Drip of 5-30 ugtts/min is equivalent to 5-30 mg/hour
12. Heparin Drip:
D5W 200 ml+ 10,000 units Heparin at 10-20
ugtts/min, use infusion pump
Concentration: 50 units/ml
Drip of 500 units -1000 units/hour is equivalent to l 0-
20 ugtts/min
Loading Dose: 3,000-5,000 units slow IV

13. Hydergine Drip: D5NM 1 liter + 6 amps Hydergine x


16-24 hours x 3 doses

14. Hydralazine(Apresoline) Drip:


D5W 250 ml + Hydralazine 2 amps (20mg/amp) at
5-30 ugtts/min (up to 60 ugtts/min)
Maximum daily dose: 3.5 mg/kg body weight per
24 hours

15. Insulin Drip: PNSS 250 ml + 50 units Humulin-R


Concentration: 0.2 units/ml
Drip of 5-50 ugtts/min (or ml/hour) is equivalent to
1-10 units Humulin R/hour

16. Isosorbide Dinitrate (Isoket) Drip:


a. D5W 90 ml+ Isoket 10 mg in a soluset
Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr.
b. If with CHF, may use double dose: D5W 90 ml+
Isoket 20 mg in a soluset
Drip of 5-25 ugtts/min is equivalent to 1-5 mg/hr

OR Glyceryl Trinitrate (Perlinganit) Drip: 1 mg/ml in 10


ml vials
a. D5W 90 ml+ Perlinganit 10 mg (1 vial) in a soluset
Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr
b. If with CHF, may use double dose 90 ml D5W+
Perlinganit 20 mg (2 vials)
Drip of 5-25 ugtts/min is equivalent to l-5 mg/hr
17. Lidocaine Drip: D5W 250 ml + Lidocaine 1 gm (pre-
mix) at 15-60 ugtts/min
Concentration: 4 mg/ml
Drip of 15-60 ugtts/ml is equivalent to 1-4 mcg/min
Formula: ugtts/min=dose x 15
Loading Dose (LD): 1 mg/kg IV
NOTE: Maintenance infusion rate must be reduced
for patients with cardiac failure or hepatic
dysfunction and for elderly patients.

18. Magnesiem Sulfate Drip: D5W 250 ml + 2 gm


MgSO4 at 20 ml/hr
Concentration: 250 mg/ml X 10 ml ampule = 2.5
gm/ampule

19. Mannitol-Furosemide Drip:


a. Mannitol 250 ml + Furosemide 100 mg at 10
ugtts/min or
b. Mannitol 36 ml + Furosemide 240 mg (24 ml) x 6
hours

20. Midazolam (Dormicum) Drip:


Preparation: 15 mg/3 ml amp 5mg/5ml amp,
5mg/ml amp
PNSS or D5W 250 ml + Midazolam 50 mg at 1-3
mg/hour; Titrate to effect.
If with fluid restrictions: Use PNSS or D5W 100 ml +
Midazolam 50 mg at 1-3 mg/hr

21. Morphine Sulfate Drip:


PNSS 50 ml + 1 amp Morphine sulfate (16 mg/amp)
at 6 ugtts/min (2mg/hr)
As needed: May give 1-3 mg morphine suite SC
PRN
22. Nicardepine Drip:
a. D5W 250 ml + Nicardepine 20 mg
Concentration: 0.08 mg/ml
Drip of 15-67 ugtts/min is equivalent to 1-5 mg/hr

OR

b. D5W 90 ml+ Nicardepine 10 mg in soluset


Concentration: 0.1 mg/ml .
Drip of 10-50 ugtts/min is equivalent to 1-5 mg/hr
Maximum dose: 15 mg/hr
NOTE: The IV infusion site must be changed every
12 hours should a peripheral line be used.

23. Nimodipine (Nimotop) Drip:


Concentration: 10 mg in 50 ml bottle
Drip of 5-10 ugtts/min is equivalent to 1-2 mg/hour
NOTE: Use larger veins and alternate IV site every
48 hours to avoid phlebitis.

24. Nitropruside (Nipride) Drip: D5W 250 ml +


Nitroprusside 50 mg as side drip at 5-30 ugtts/min
(usual dose)
Concentration: 0.2 mg/ml or 200 mcg/ml
Drip of 0.5-8 mcg/kg/min is equivalent to 8-120
ugtts/min for a 50 kg patient
Formula: ugtts/min (dose x BW kg)/3.3
NOTE: Taper within 3 days to avoid thiocyanate
toxicity. Cover infusion set and IV line with
aluminum foil or carbon paper.

25. Noradrenaline(Levophed) Drip: 2 mg


Noradrenaline in 2 ml ampule
D5W 250 ml+ 1 amp Noradrenaline at 15-60
ugtts/min
Concentration: 8 mcg of Noradrenaline per ml
Drip of 2-8 mcg Noradrenaline/min is equivalent to
15-60 ugtts/min

26. Pentoxifylline (Trental) Drip:


a. D5W 250-500 ml + 1 amp Trental 300 mg x 6 hours
for 1 dose then PO Trental 400 mg 1 tab TID
b. D5W 500 ml + 3 amps Trental (900 mg) x 24 hours

27. Sodium Bicarbonate Drip:


D5W 250 ml + NaHCO3 1 amp (8.4%-50ml vial) X 12-
24 hours (or at 20-40 ugtts/min)

28. Somatostatin (Stilamia) Drip:


Give 250 mcg slow IV then
a. D5W 500 ml + 3 mg Somatostatin at 42 ml/hr (250
mcg/hr)
OR

b. D5W 250 ml + 3 mg Somatostatin (Stilamm) at 21


ml/hr (250 mcg/hr) until GI bleeding has stopped
or up to 5 days

29. Streptokinase (Streptase, Kabikinase) Drip:


Streptokinase 1.5 million units + Dy5 90 ml at 100
ml/hr (1 hour running rate)

30. Terbutaline (Bricanyl) Drip: D5W 250 ml + 5 amps


Bricanyl at 10-30 ugtts/min
Guideline to oral switch of antibiotic therapy

Considerations for the early switch to oral therapy COMS


 review at 24-48 hours

 Clinical improvement observed


 Oral route is not compromised
 vomiting, malabsorptive disorder, NBM, swallowing
problems, unconscious, severe diarrhea)
 NB: if NG/PEG feeding then please consult your
pharmacist
 Suitable oral antibiotic option available
 Markers showing a trend towards normal:
 Patient should be apyrexial for the last 24 hours
(Temp>36⁰C and <38⁰C)
 NOT have more than one of the following
 heart rate>90/min
 resp rate>20/min
 BP unstable
 WCC<4 or>12
 White cell count should show a trend towards
normal
 Absence of such should not impede the switch if
all other criteria are met and not neutropenic.
 Specific indication/deep-seated infection
 Deep seated infections that may require an initial
two weeks of IV therapy
 Liver abscess
 Osteomyelitis, Septic arthritis
 Empyema
 Cavitating pneumonia
 High risk infections requiring prolonged IV therapy
 Staphylococcus aureus bacteremia
 Severe necrotizing soft tissue infections
 Severe infections during chemotherapy related
neutropenia
 Infected implants/prosthesis
 Meningitis/encephalitis
 Intracranial abscesses
 Mediastinitis
 Endocarditis
 Exacerbation of cystic fibrosis/bronchiectasis
 Inadequately drained abscesses or empyema

Suggested Conversion Regimens

IV Oral
1 – 2 g IV 500mg – 1g PO
Ampicillin Amoxicillin
QID TID
500 mg IV
Azithromycin Roxithromycin 300 PO OD
OD
Benzyl Phenoxymethyl
1.2g IV QID 500mg PO QID
penicillin penicillin
No oral formulation
Ceftriaxone 1g IV OD Choice of oral antibiotic depends on
infection site/microbiology
Cephazolin 1g IV TID Cephalexin 500mg PO QID
200‐400mg 250‐500mg PO
Ciprofloxacin Ciprofloxacin
IV BID BID
Flucloxacillin 1g IV QID Flucloxacillin 500mg PO QID
600‐900mg 300‐600mg PO
Lincomycin Clindamycin
IV TID TID
200‐400mg 200‐400mg PO
Fluconazole Fluconazole
IV OD OD
500mg IV
Metronidazole Metronidazole 400mg PO TID
BID
Common Pediatric Medicine Recommended Dose

ANTIBIOTICS
Loading Dose
15mg/kg
Amikacin 50, 100, 500 mg/vial
Maintenance Dose
10mg/kg/day IV OD
100mg/ml
Amoxicillin 125mg/5ml 30-100 mg/kg/day, TID PO
250mg/5ml
Amoxicillin content:
Amoxicillin + 125mg/5ml;
Clavulanic acid OR 250mg/5ml 30-50 mg/kg/day, BID or TID PO
Co-amoxiclav 200mg/5ml;
400mg/5ml
Amoxicillin 250/250mg/5ml
30-50mg/kg/day TID, PO
+Sulbactam 500mg/250mg/vial
75-100mg/kg/day Q6-8, IV
(Ultramox) with diluent
50-100 mg/kg/day
Ampicillin 100,250,500 mg/vial Meningitis
200-400 mg/kg/day; Q6 IV
30-50mg/kg/day BID, PO
Ampicillin +
250mg/5ml 150mg/kg/day IVT Q8
Sulbactam
375,750,1.5g/vial (max 6 g for mild)
(Unasyn)
(max 12 g for severe)
Day 1
10 mg/kg on
Azithromycin 200mg/5ml
Day2-3
5mg/kg/day on BID, PO
50mg/ml;
Cefaclor
125 mg/5ml; 20-40 mg/kg/day; Q8, PO
(2nd gen)
250 mg/5ml
Cefadroxil
250mg/5ml 25-50 mg/kg/day; TID, PO
(1st gen)
Cefalexin 125mg/5ml
25-50 mg/kg/day; TID, PO
(1st gen) 250mg/5ml
Cefazolin
500mg, 1g/vial 50-100 mg/kg/day; Q6-8, IV
(1st gen)
4-8mg/kg/day BID;
Cefixime 20mg/ml
Typhoid fever
(3rd gen) 100mg/5ml
20mg/kg/day BID PO
Cefotaxime
500mg. 1g, 2g.vial 50-150 mg/kg/day; Q6-12, IV
(3rd gen)
Ceftazidime
250, 500mg,1g/vial 50-100 mg/kg/day; Q8-12, IV
(3rd gen)
Ceftriaxone
250, 500, 1g/vial 50-100 mg/kg/day; Q12 or OD, IV
(3rd gen)
250, 759mg/vial
Cefuroxime 20-30 mg/kg/day BID PO
125mg/5ml
(2nd gen) 50-100 mg/kg/day; Q8 for IV
250mg/5ml
125mg/5ml
Chloramphenicol 50-100 mg/kg/day; Q6 PO or IV
1g/vial
125mg/5ml
Clarithromycin 7.5-15 mg/kg/day BID, PO
250mg/5ml
10-30 mg/kg/day; TID, PO
Clindamycin 75mg/5ml
25-40 mg/kg/day; Q6-8, IV
125 mg/5ml
Cloxacillin 250 mg/5ml 50-100 mg/kg/day; Q6 IV or PO
250, 500 mg/vial
200/40/5ml
5-8 mg/kg/day (based on Trim);
Cotrimoxazole 400/80/5ml
BID
(Trim/Sulfa)
Doxycycline 25mg/5ml 2-4 mg/kg/day; BID, PO
Erythromycin 200, 400 mg/5ml 30-50 mg/kg/day; Q6, PO
Gentamycin 20, 40, 80 mg/vial 5-8 mg/kg/day; OD
250, 500, 750mg/tab
10 mg/kg/dose; OD – BID
Levofloxacin 5mg/ml solution for
(max: 500mg/day)
IV infusion, 100ml
Mild to moderate
60mg/kg/day
Meropenem 500mg, 1g/vial
Severe
120mg/kg/day; Q8, IV
Oxacillin 500mg; 1gram/vial 100-300 mg/kg/day; Q4-6h IV
600T u/vial
Penicillin G 600,000 u/kg IM, every 21 days
1.2M u/vial
Benzathine (max: 1.2 mil U/dose)
2.4M u/vial
Penicillin G 5mil u/vial 100,000-300,000 U/kg/day, Q6 IV or
Sodium 1mil n/vial as DRIP
Piperacillin + 2g/250mg/vial
150-300mg/kg/day; Q6, IV
Tazobactam 4g/500mg/vial
125mg/5ml
Tetracycline 25-50 mg/kg/day; TID, PO
250; 500mg cap
Vancomycin 500mg/vial 40-60mg/kg/day; Q6 as DRIP
ANTI-VIRAL
200mg cap
15-30mg/kg/day IVT Q8-12
Acyclovir 400, 800mg tab
80mg/kg/day TID, PO
200mg/5ml susp
6 – 12yo
5ml 6 x a day, PO
2 – 6yo
3ml 6 x a day, PO
Inosiplex 250mg/5ml 1 – 2yo
(Immunosine) 500mg tab 2ml 6 x a day, PO
6mons – 1yo
1.5ml 6 x a day, PO
<6mons
1ml 6 x a day, PO
Loading Dose
Methixoprinol
100mg/kg/day
Linosine 250mg/5ml
Maintenance Dose
(Isoprinosine)
50 mg/kg/day, PO
ANTI-FUNGAL
Test dose:
0.1 mg/kg/dose; infuse over 20-
60mins
If tolerated:
Amphotericin B 50 mg/vial start therapeutic dose at 0.25
mg/kg/day
Maintenance dose:
0.25-1 mg/kg/dose OD; infuse over
2-6 hours
12mg/kg IV or PO
Fluconazole
50,150,200mg cap Loading dose
2g/vial 6mg/kg IV or PO then
maintenance dose OD
Miconazole
(Daktarin oral Oral gel 2% Apply to mouth lesions TTD or QID,
paste) local application

Nystatin 100,000 U/ml susp 0.5-1 ml to each side on mouth


QID; local application
AMOEBICIDALS
Diloxanide furoate 500mg/tab Adult: 1 tab TID
Amoeba:
Child: 30-50 mg/kg/day; TID, PO
125, 250mg/5ml
Metronidazole Anaerobes:
500mg, 1g/vial
Neonate: 7.5 -15 mg/kg/day IV
OD, Q12, Q8
Child: 30mg/kg/day Q8 IV or PO
ANTI-HELMINTICS
Albendazole
100mg/5ml 20ml OD, PO
(Zentel)
Mebendazole 100mg/5ml
200mg/day; BID for 3 days, PO
(Antiox)
Pyrantel Pamoate 100mg/5ml
(Combatrin, 250mg/5ml 11 mg/kg/day BID for 3days,PO
Quantrel)
For DIARRHEA
< 6mons
½ neb BID x 3-5 days, PO
Bacillus clausii In nebule > 6mons
(Erceflora) 1 neb BID x 3-5 days, PO
NOTE: may mix with sweetened
water, milk or juice.
Bifidobacterium /
capsule
Lactoba cillus 1 cap mixed with milk TID,PO
(Infloran)
Nifuroxazide
220mg/5ml 10-15ml OD x 7 days, PO
(Ercefuryl)
ORS In sachets 10cc/kg; Qlbm, PO
1 sachet OD
In sachet
Protexin NOTE: may mix with sweetened
water, milk or juice
1.5mg/kg/ds (BID or TID) until
In sachets of 30mg,
Racecodotril cessation of diarrhea
10mg
(Hidrasec) NOTE: may mix with sweetened
water, milk or juice
ANTI-EMETICS
5mg/ml
Domperidone
5mg/5ml 0.2-0.4mg/kg/dose Q4-8, PO
(Vometa, Motilium)
5mg/5ml
Metochlorpromide 0.2-0.5 mg/kg/day Q8 IV or PO
10mg/2ml vial
ANTI-SPASMODICS
6 – 12yo:
5ml, PO Q6
5mg/ml drops
Dicycloverine 2 – 5yo:
10mg/5ml
(Relestal) 2.5-5ml, PO Q6
20mg/5ml
6mon – 2yo:
0.5-1ml, PO Q6
Hyoscine 20mg/amp
0.3-0.6mg/kg in slow IV Q6
(Buscopan)
STEROIDS
ICP
0.05mg/ml syr 0.5-1mg/kg/day or 6mg/m2 Q4 or
Dexamethasone 4,5mg inj Q6
Laryngeal edema
0.5mg/kg then 0.25mg/kg/day
Loading Dose
4-8 mg/kg then
Hydrocortisone 100,250,500 mg/vial
Maintenance Dose
2-4 mg/kg/dose
Prednisone 10mg/5ml 1-2mg/kg/day; PO
ANTI-ULCERS
Cimetidine 200mg/2ml 20-40mg/kg/D; Q6, IV
Ranitidine 25mg/ml 2-4mg/kg/D; Q6; Q8, IV
Omeprazole 40mg/10ml 0.5-1mg/kg IVT OD, IV
ANTICONVULSANTS
Diazepam 2,5,10mg tab 0.12-0.8mg/kg/day Q6-8
(Valium) 10mg/2ml inj 0.04- 0.2mg/kg/dose IV
Loading Dose
125mg/5ml
Diphenylhydantoin 5-10mg/kg
30mg/5ml
(Dilantin) Maintenance Dose
10mg/2ml
5mg/kg/day IV or PO
Loading Dose
130mg/ml amp 10-20mg/kg/dose
Phenobarbital
Maintenance Dose
5-8mg/kg/day Q12 IV or PO
30mg/cap
6-8mg/kg/day BID; TID
100mg/cap
Phenytoin Older
30mg/5ml
3-4mg/kg/day BID
125mg/ml
ANTIHYPERTENSIVES
10mg/tab 0.1-0.2mg/kg/day OD
Amlodipine
5mg/tab (max: 0.6mg/kg/day)
25mg/tab 0.3-0.5mg/kg/dose TID
Captopril
50mg/tab (max: 6mg/kg/day)
5mg/tab
0.08mg/kg/day OD-BID
Enalapril 10mg/tab
(max: 0.6mg/kg/day)
20mg/tab
1-2mg/kg/day
Hydralazine 10,25,50mg tab (max: 8m/kg/day)
(Apresoline) 20mg/amp Hypertensive Encephalopathy
IV: 0.1-0.2mg/kg
Nifedipine 0.25-0.5mg/kg/dose; Q4-Q6
5, 10 cap
(Calcibloc) sublingual PRN
10,40 mg tab
l-2mg/kg/day; Q6-Q8, PO
Propanolol 10mg/amp
(max: 10-12m/k/day)
DIURETICS
Neonate:
20,40 mg tab
0.5-1mg/kg/dose
Furosemide 20mg/2ml inj
Child:
0.5-2mg/kg/dose Q6-Q12, IV or PO
25,50,100mg tab 1mg/kg/day PO
Spironolactone
(max: 3mg/kg/day)
ANTI-HISTAMINE
2.5mg/5ml
Chlorphenamine 0.2mg/kg/dose PO
100mg/ml
Cetirizine 5mg/5ml
0.25mg/kg/dose OD, PO
(Alnix, Allerkid) 2.5mg/ml
6 – 12yo:
5ml OD, PO
Desloratidine 2.5mg/5ml 1 – 5yo:
(Aerius) 2.5ml OD, PO
6mon – 11mon:
2ml OD, PO
12.5mg/5ml
Diphenhydramine 3-5mg/kg/day or 1mg/kg/dose IV
50mg/amp
Hydroxyzine
2mg/ml 1mg/kg/day, PO
(Iterax)
Levocetirizine 2.5mg/5ml 0.125mg/kg/dose OD PO
Loratidine 5mg/5ml 0.25mg/kg/dose OD PO
BROCHODILATORS
Doxofylline
100mg/5ml 6-9mg/kg BID, PO
(Ansimar)
> 15yo:
10mg tab OD PO
4mg tab, 6 – 14yo:
Montelukast
5mg/tab,10g/tab 5mg tab OD
2 – 5yo:
4mg tab OD
Procaterol 5mcg/ml syr
0.25mg/kg/dose BID, PO
(Meptin) 25mcg tab
Salbutamol 2mg/5ml 0.15mg/kg/dose TID, PO
Oral:
Terbutaline 1.5mg/5ml 0.75mg/kg/dose
(Bricanyl) 0.5mcg/ml amp SQ:
0.005-0.01 mg/kg/dose
ANTI TUBERCULOSIS
Ethambutol 125mg/5ml 15-25 mg/kg/day, PO
Isoniazid 200mg/5ml 10-15 mg/kg/day, PO
Pyrazinamide 250mg/5ml 20-30mg/kg/day, PO
Rifampicin 200mg/5ml 10-15 mg/kg/day, PO
Streptomycin lg/vial 20-40 mg/kg/day IM
ANALGESICS/ANTIPYRETICS
Ibuprofen 5-10mg/kg/dose Q6, PO
100mg/5ml
(Dolan) NOTE: <12yo
Mefenamic acid 10-20mg/kg/day Q6, PO
50mg/5ml
(Ponstan) NOTE: ≥12yo
100mg/ml
Paracetamol 10-15mg/kg/dose Q4, PO, IV
120, 250mg/5ml

Cough/Cold Preparation
Examples Age Empiric Doses: per orem
Ambroxol < 6mon 1/4 tsp TID,QID
Carbocisteine 6mon – 2yo 1/2 tsp
Mucosolvan 2 – 6yo 1 tsp
Sinecod 6 – 9yo 1.5 tsp
PPA 9 – 12yo 2 tsp
Emergency medicine for pediatrics

Recommended dose
Drugs Computation
0.04mg/kg SC
Atropine
0.01 – 0.02m/k/dose IV OR ET
Hypertensive Crisis:
Diazoxide IV 1 – 2mg/kg given in 15 – 30sec
Max: 5mg/kg (LD)
For asystole and bradycardia:
IV/ET 0.1 – 0.3 ml/kg Q3 – 5 mins
(1:10,000 dilution or 0.1 mg/ml)
Epinephrine
(1:1000 solution) For anaphylaxis
0.01mg/kg IM at the mid-antero-lateral
aspect of thigh
(1:10,000 dilution or 0.1 mg/ml)
Glucagon 0.03mg/kg SC, IM or IV
IV 0.1 – 0.5mg/kg
Hydralazine
Max: 2mg/kg IV; Q3-6hrs
Diabetic Ketoacidosis:
Insulin
IV infusion 0.05 – 0.1 U/kg/hr
0.25g/kg IV OR 5cc/kg IV bolus
Mannitol
(max : 1 – 2g/kg w/in 2 – 6hrs)
1 – 2 mEq/kg/dose IV
NaHC03
(0.5 mEq/ml sol’n in NB)
Other Drugs

Pain

 NSAIDS
 ASA 80-160 mg PO OD
 Paracetamol 500-650 mg PO up to q4
 Ibuprofen 400 mg PO up to q4
 Naproxen 250-500 mg up to q12
 Ketorolac 15-60 mg IM/IV up to q4
 Celecoxib 100-200 mg PO up to q12
 Advantages
 Deals well with inflammatory pain (muscle and
joint pain, malaise from infection, etc.)
 Absorbed well from the GI tract
 Disadvantages
 GI irritation (except paracetamol)
 Peptic ulcer
 Nephropathy
 Increases blood pressure
 Selectivity for COX-2
 Decreases GI symptoms
 Increases cardiovascular risk
 Narcotics
 Tramadol 50-100 mg PO up to q4
 Morphine 60 mg PO up to q4 (need S2)
 Advantages
 Broadest efficacy
 Very rapid especially if IV
 Disadvantages
 Nausea and vomiting
 Constipation
 Sedation
 Respiratory depression

 Anti-convulsants
 Phenytoin 300 mg @ HS
 Carbamazepine 200-300 mg up to q6
 Clonazepam 1mg up to q6
 Gabapentin 600-1200 mg up to q8
 Pregabalin 150-600 mg up to BID
 Advantages
 Effective for neuropathic pain (e.g. trigeminal
neuralgia, DM nephropathy)
 Disadvantages
 Hepatic toxicity, Dizziness, GI symptoms
 Heart conduction disturbances

Fever

 Paracetamol 300 mg IVTT q4hrs; PRN for Temp ≥ 38ºC


 Paracetamol 10-15 mg/kg/dose IVTT OR PO q4hrs; PRN
for Temp ≥ 38ºC

Itchiness

 Calmoseptien (Calamine plus Zinc oxide) BID OR q6hrs;


PRN for itchiness

Diaper Rash

 Zinc oxide OD OR BID


 Vandol BID OR TID
 Enfacare diaper rash, apply every after diaper change

Teething

 Xylogel natural teething oral gel, apply liberal on


affected area as needed

Decrease Appetite

 Buclizine + MV tab OD
 Vitamin B complex
Oral Sores

 Miconazole (Daktarin) oral gel BID

Frank Seizure

 Diazepam 1 amp; PRN for frank seizure


 Diazepam 0.2 mg/kg/dose slow IVTT; PRN for frank
seizure

Vertigo

 Betahistine 16 mg TID x 5 days


 Cinnarizine 75 mg OD OR BID OR 30 mg TID

Impacted Cerumen

 Otosol 3 – 5 gtts on affected ear x 7 days


 Return after 7 days for removal of impacted
cerumen

Vomiting

 Metoclopromide 10 mg PO q6hrs; PRN for vomiting


 Metoclopromide 0.2 – 0.5 mg/kg/day IVTT OR PO q8hrs;
PRN for vomiting
 Adverse effect: EPS and tardive dyskinesia
 Domperidone 20 mg PO q4-8hrs; PRN for vomiting
 Domperidone 0.2 – 0.4 mg/kg/dose PO q4-8hrs; PRN for
vomiting
 Caution with Parkinson’s and contraindicated with
pyloric stenosis

Tinnitus

 Ofloxacin 3 gtts
 Cetirizine
Laxatives
 Bisacodyl (Dulcolax) 5 mg tab, PO 1-2 tabs HS
 Bisacodyl 10 mg suppository, Per Rectum
 Lactulose (Duphalac) PO-1-2 tbsp HS
 Mg(OH)2 (Phillips Milk of Magnesia) 311 mg tab, PO, 2-4
tabs
 Mg(OH)2 425 mg/5 ml syrup, PO, 2-4 tbsp in 1/2 glass of
H2O
 Na Picosulfate (Laxoberal) 5 mg tab PO- 1-2 tab HS
 Na Picosulfate 1 mg/ml syrup PO- 1-2 tsp HS
 Psyllium Hydrophilic Mucilloid (Metamucil) 5.9 gm
sachet, PO 1 sachet/glass of water OD-TID
 Standardized Senna Concentrate (Senokot) 187 mg
tab, PO, 2-4 tabs OD-BID
 Standardized Senna Concentrate 0.337 mg/3 gm
granules, PO, 1-2 tsp granules BlD

Anti-diarrheals

 Attapulgite (Polymagma, Diatabs) 600 mg tab, PO, 2


tabs initially then after each LBM, max =16 tabs/day
Attapulgite 600 mg/5 ml susp, PO, 2 tsp initially then
after each LBM, max = 90 ml/day
 Loperamide HCl (Imodium, Lormide) 2 mg cap, PO, 2
caps initially then 1 cap after each LBM, maximum =
6caps/day
 Nifuroxazide (Ercefuryl) 200 mg cap, PO, 1 cap QID
 Paromomycin (Humagel) 150 mg cap, PO, 1-2 caps q
3-5 hr
 Paromomycin susp, PO, 1-2 tbsp q 3-5 hr
 Diphenoxylate HCl + Atropine (Lomotil) tab, PO, 2 tabs
TID-QID
Ear Drops

 Antibiotics
 Aerosporin (3 drops TID)
 Garamycin (3 drops BID)
 Inoflox (3-5 drops BID)
 Lignosporin with Lidocaine (3 drops TID)
 Chloramphenicol (2 drops QID)
 Antibiotics with Corticosteroids:
 Aplosyn otic (3-4 drops BID or QID)
 Cortisporin (3-4 drops BID or QID)
 Garasone (3-4 drops BID or QID)
 Others:
 Otosol
 Irwax
Auralgan

Topical Meds

 Topical Antibiotics:
 (Bactroban)
 Gentamycin
 Silver Sulfadiazine
 Topical Antibiotics 4- Steroids
 (Betnovate)
 Topical Antifungal
 Fungistin
 Miconazole
 Topical Antifungal + Steroids
 Aplosyn C
 Topical Antifungal + Steroid + Antibacterial
 Triderm
 Topical Antifungal + Steroid + Antibacterial +
Antihistamine
 Quadriderm
 Topical Antihistamine
 IIWSQ
ELECTROLYTES
Doctors’ Guide
General Management Strategy
 Monitor serum potassium, magnesium and calcium
frequently in patients with vomiting/diarrhea and
patients receiving injectable.
 Check for signs of dehydration in patients with vomiting
and diarrhea. Start oral or intravenous rehydration
therapy immediately until volume status is normal.
 Check ECG in patients with significant serum
electrolyte disturbances. Drugs that prolong the QT
interval should be discontinued in patients with
evidence of QT interval prolongation.
 Electrolyte abnormalities are reversible upon
discontinuation of the injectable. Even after
suspending the injectable, it may take weeks or
months for this syndrome to disappear, so electrolyte
replacement therapy should continue for several
months after completion of the injectable phase of
multidrug-resistant tuberculosis (MDR-TB) treatment.
 Hypokalaemia and hypomagnesaemia are common
in patients receiving MDR-TB treatment
Hypokalemia
 Hypokalaemia - serum potassium <3.5 mEq/l.
 Severe hypokalaemia or symptomatic
hypokalaemia is <2.0 mEq/l
 Hospitalization is necessary in severe cases of
hypokalaemia.
 Hypokalaemia may be refractory if concurrent
hypomagnesaemia is not also corrected.
 If unable to check serum magnesium, give empiric
oral replacement therapy in all cases of
hypokalaemia with magnesium gluconate, 1000 mg
twice daily.
 Dietary intake of potassium should be encouraged -
Bananas, oranges, tomatoes and grapefruit juice
Amiloride 5 to 10 mg orally daily or spironolactone
25 mg orally daily may decrease potassium and
magnesium wasting due to the injectable

Potassium
Dosing Monitoring frequency
level
> 3.5 None Monthly
3.3 – 3.5 40 mEq PO OD Monthly
60 – 80 mEq PO
2.9 – 3.2 Weekly
OD
2.7 – 2.8 60 mEq PO TID One to two days
2.4 – 2.6 80 mEq PO q8h Daily
10 mEq/hr IV and One hr after indusion,
< 2.4
80 mEq PO q6-8h q6h with IV replacement

NOTE: The normal preparation of a potassium chloride


infusion is 40 mEq in 200 ml of normal saline. Do not
exceed an infusion rate of 20 mEq/hr (100 ml/hr).
KCl computation

KCl incorporation (maintenance)

Desired potassium dose= 2-4 mEqs/kg/day

STEP 1: Compute for the desired dose of Kl1 in a given


volume using formula below:

Example:
 Desire dose = 3 mEqs/kg
 D5LR Volume = 1000ml
 IV rate = 42 ugtts/min (Holiday-segar)
 Patient Weight = 10kg

= 30,000
1,008
= 29.7mEqs

Sample Orders:
 IV: D5LR 1Liter + 30mEqs KCL to run in 42ugtts/min
KCl correction

If patient serum POTASSIUM is ≤ 2 mmol/L, do fast


correction at 0.5 mEqs/kg to run in 1hour.

STEP 1: Determine the patient’s weight.

STEP 2: Determine how much K+ is needed


Formula
)
Example: weight is 20kg
)

STEP 3: Determine which route will be used (central line or


peripheral line)

STEP 4: Compute how much diluent is required


A. Central Line (200 mEq/L)
Formula:

Example: from STEP 1, K+ required is 10 mEq/hr


)
= 50 mL/hr
Sample Order:
 Incorporate 10 mEq of KCl in 50mL PNSS and run in 1hr
B. Peripheral Line (60 mEq/L)
Formula:

Example: from STEP 1, K+ required is 10 mEq/hr


)
= 166.66 or 170 mL/hr
Sample Order:
 Incorporate 10 mEq of KCl in 170mL PNSS and run in 1hr

NOTE
 K correction using peripheral line only used in volume
depleted patients
 KCl is a dangerous drug if accidentally given as fast
drip, so it is warranted to accurately regulateits
administration
 Repeat serum K+ 6hours after end of KCl drip, if still low
may consider to give another correction until serum K +
is 3.5mEqs/L (SI: 3.5mmol/L)
Hypomagnesaemia
 Hypomagnesaemia is defined as serum magnesium
<1.5 mEq/l.
 If unable to check serum magnesium, give empiric oral
replacement therapy in all cases of hypokalaemia with
magnesium gluconate, 1000 mg twice daily.
 Amiloride 5 to 10 mg orally daily or spironolactone 25
mg orally daily may decrease potassium and
magnesium wasting due to the injectable and may be
useful in severe cases that are refractory to
replacement therapy.

Magnesium Monitoring
Dosing
level frequency
> 1.9 None Monthly
1000 mg – 1200
1.5 – 1.9 Monthly
mg
1.0 – 1.4 2000 mg One to seven days
3000 mg – 6000
< 1.0 Daily
mg
NOTE: Quantities greater than 2000 mg are usually given by
IV or intramuscular (IM). The normal preparation is
magnesium sulfate 2 g in 100 ml or 4 g in 250 ml of 5%
dextrose or normal saline. Do not exceed an infusion
rate of 150 mg/min (2 g in 100 ml administered over
one to two hours, 4 g in 250 ml administered over two
to four hours).
Hypocalcaemia

Calcium Monitoring
Dosing
level* frequency
> 8.5mg/dl
None
(>4.2mEq/l)
7.5 – 8.4 500 mg TID Monthly
One to two
7.0 – 7.4 1000 mg TID
weeks
Consider IV and taper One to four
< 7.0
to 1000 mg TID days

*total nonionized calcium value adjusted for low albumin


NOTE: Normal calcium is 8.5–10.3 mg/dl (2.12–2.57 mmol/l).
To adjust for low albumin in nonionized values of
calcium, use this formula: Corrected calcium = 0.8 ×
(4.0 – measured albumin) + reported calcium. If ionized
calcium is being tested, it does not need to be
adjusted for low albumin and normal value is 4.5–5.6
mg/dl (1.11–1.30 mmol/l).
LABORATORY
Doctors’ Guide
Urinalysis
Urine Color Cause
Faint yellow Normal
White Pus, chyle, phosphate crystals
Pink / red /
brown RBCs, hemoglobin, myoglobin, beets, senna,
(tea methyldopa, metronidazole, food coloring
colored)
Yellow / Bilirubin, B complex, rifampicin, iron,
orange nitrofurantoin, phenytoin
Brown /
Methamoglobin, melanin
black
Blue /
Pseudomonas, dye, chorophyll
green

Values Clinical cause


1.000 –
Diabetes insipidus
1.005
Specific 1.003 –
Normal
gravity 1.030
Dehydration, contrast, dyes,
> 1.030
glucose, mannitol
Clear Normal
Turbidity Milky
Infection, crystals, chyluria
white
< 4.5 Acidic urine : uric acid crystals
4.5 – 6 Normal
Urine pH
Alkaline urine : vegetarian diet,
> 6.0
UTI, Renal tubular acidosis
Total protein <150mg/24hrs
Urine Albumin <30mg/24hrs
Negative
protein Regular dipstick detects only
albumin > 300mg/L
Proteinuria
 24 hr urine collection – cumbersome, prone to
collection error
 Albumin / creatinine ratio is a simple and accurate
method of quantifying proteinuria
 Ex. A/C ratio of 200 mg protein/Gm crea equivalent
to urine protein of 200mg/24h
 Urine Electrophoresis – to determine type of protein

Microalbuminuria
 Marker of silent DM nephropathy
 Significant predictor or overt nephropathy
 First manifestation of injury to the glomerular filtration
barrier

 Types of Proteinuria

 Orthostatic or Postural
 Functional
 High fever, exercise, heat stroke, CHF
 Glomerular
 Tubular
 Overflow
 Hyperglobulinemic states
Urine Microscopy
Component Types
Urates, calcium, oxalate, triple
Crystals
phosphates, cystine, drugs
Red blood cells, white blood cells, tubular
Cells
cells, fat bodies, squamous cells
Casts Hyaline, granular, RBC, WBC, broad, waxy
Organisms Bacteria, yeasts, trichomonas
Miscellaneous Spermatozoa, mucus treads

Cells and Casts Normal Pathology


1–4
Leucocytes UTI, interstitial nephritis
/hpf
0–2 Stones, obstruction, UTI,
Erythrocytes
/hpf glomerular
Tubular cells Few Renal failure
Hyaline casts Few Dehydration
Course granular
None CKD
casts
Muddy brown
None Acute tubular necrosis
casts
WBC casts None Pyelonephritis
RBC casts None Glomerulonephritis

Hematuria
 May originate anywhere from the glomerulus to the
urethral meatus
 Normal: RBC in the urine is between 0 – 2 / HPF
 Abnormal: > 3 RBC / HPF
 Shape of RBC is important:
 Normal shape RBC – originate from collecting system
 Dysmorphic RBC - originate from glomerulus
Causes of hematuria
Hematuria + proteinuria, Glomerular pathology
RBC casts
Hematuria coincident with IgA nephropathy
URTI, occasional proteinuria
Hematuria days or weeks Acute post-streptococcal
after URTI glomerulonephritis
Hematuria with Pyuria UTI, glomerulonephritis
Hematuria, Crystals Stone disease

Other cells
 Eosinophils – seen in allergic interstitial nephritis,
atheroembolism
 Epithelial cells
 squamous cells – contaminant
 transitional cells – from pelvis to urethral lining renal
tubular cells - large amount seen in ATN

Other causes of pyuria


 Contamination during collection
 Vaginal secretions
 Foreskin secretions
 Non-infectious causes
 VesicoUreteral Reflux
 Analgesic Nephropathy
 Uric acid nephropathy
 Polycystic kidney
 ATN
 Transplant rejection
 Allergic interstitial nephritis
 Sarcoidosis
 Radiation nephritis
 Hypercalcemic nephropathy
 Lithium toxicity
 Hyperoxalosis
 Heavy metal toxicity
 Carcinoma of Urinary tract
 Renal calculi
 Sickle cell disease
 Idiopathic interstitial cystitis
 Glomerulonephritis
 Infectious diseases
 TB
 chlamydial / gonococcal urethritis
 Leptospirosis,
 Viral cystitis
 Infections adjacent to urinary tract
 Appendicitis
 Diverticulitis

Clinical Syndromes of Renal Disease


Site of injury Urinalysis findings Examples
Glomerulus  Hematuria  Nephritic
(dysmorphic) syndrome
 Pyuria  Nephrotic
 Proteinuria syndrome
 Cells, casts  IgA nephropathy
Tubules  Abnormal urine  Urinary tract
interstitium specific gravity, infection
pH  Unrinary tract
 Proteinuria obstruction
 Hyaline casts  Renal tubular
 Hematuria, pyuria acidosis (RTA)
Vascular  Bland sediments  Hypertension
 (no cells, hyaline
casts)
Nephrotic vs Nephritic Syndromes
Features Nephrotic Nephritic
Onset + Abrupt
Edema ++++ ++
BP Normal Raised
JVP Normal/low Raised
Proteinuria ++++ ++
May/may not
Hematuria +++
occur
RBC casts Absent Present
Normal/ slightly
Albumin Low
decreased
Serum Creatinine

 Mainly derived from metabolism of


creatine/creatine phosphokinase from skeletal
muscle cells
 Produced in almost constant rate
 Steady state concentration dependent on renal
excretion w/c mainly reflects of GFR

Cockcroft-Gault Formula*

) )
)

*Multiply result by 0.85 for female


CrCl normal values = 90 – 120 ml/min
Normal decline rate 1 ml/min/yr after age 40
Serum creatinine alone is not a good indicator of
estimated GFR

Creatinine Clearance
 Widely used method to estimate GFR

(Timed urine collection


 Quick estimation of creatinine clearance use
Cockcroft-Gault formula and MDRD formula
Factors that can affect BUN levels
 Increase levels – high protein intake,
hyperalimentation GI bleeding, Catabolic states,
Steroids, Tetracyclines, volume depletion
 Decrease levels – liver disease, pregnancy
 BUN to Creatinine ratio
 Normal = 10 – 20 : 1
 Volume depletion (Prerenal) = > 20 :1

Factors Affecting Markers of Kidney Function


RIFLE classification of Acute Kidney Injury
Differentiating Acute vs Chronic Renal Failure

Points favoring CRF:


 History
 Prior history of DM, HPN, Renal or GU disease
 Review of old medical records
 Onset of nocturia
 Physical Exam
 Pallor, Skin changes
 Lab
 Severe anemia, elevated PTH and phosphorus, low
serum calcium
 Radiology
 Bilateral small kidneys, osteodystrophy (bone
changes)

NOTE: Acute injury on top of chronic kidney is common


Normal Values (Pediatrics)

Albumin:
 Adult 3.5-5.0 g/dL (SI: 35-50 g/L)
 Child 3.8-5.4 g/dL (SI: 38-54 g/L)

Albumin/Globulin Ratio (A/G):


 Normal >1. A calculated value (Total protein minus
albumin = globulins.
 Albumin divided by globulins=A/G ratio).
 Serum protein electrophoresis is a more informative
test.

Alkaline Phosphatase:
 Adult 20-70 U/L
 Child 20-150 U/L

ALT (Alanine Aminotransferase, ALAT) OR SGPT:


 0-35 U/L (SI: 0-0.58 mkat/L), higher in newborns

Ammonia:
 Adult 10-80 mg/dL (SI: 5-50 mmol/L).
 To convert mg/dL to mmol/L, multiply by 0.5872

ASO (Antistreptolysin O/Antistreptococcal O)


TITER (STREPTOZYME):
 <200 IU/mL (Todd units) school-age children.
 <100 IU/mL preschool and adults. Varies with labs.

AST (Aspartate Aminotransferase, ASAT) OR SGOT;


 8-20 U/L (SI: 0-0.58 mkat/L)

Bicarbonate (or “total C02”):


 23-29 mmol/L

Bilirubin:
 Total, 0-3-1.0 mg/dL (SI: 3.4-17.1 mmol/L).
 Direct, <0.2 mg/dL (SI: <3.4 mmol/L).
 Indirect, <0.8 mg/dL (SI: <3.4 mmol/dL).
 To convert mg/dL to mmol/L, multiply by 17.10

Blood Urea Nitrogen (BUN):


 Birth-1 year: 4-16 mg/dL (SI: 1.4-5.7 mmol/L).
 1-40 years: 5-20 mg/dL (SI: >15-20 mg/dL (SI: >257-342
mmol/L in full-term infants)

BUN/Creatinine Ratio (BUN/CR):


 Mean 10, range 6-20

C-Reactive Protein (CRP)


 Normal = none detected.

Calcium, Serum:
 Infants to 1 month: 7-11.5 mg/dL (SI: 1.75-2.87
mmol/L).
 1 month to 1 year: 8.6-11.2 mg/dL (SI: 2.15-2.79
mmol/L).
 >1 year and adults: 8.2-10.2 mg/dL (SI: 2.05-2.54
mmol/L).
 Ionized: 4.75-5.2 mg/dL (SI: 1.19-1.30 mmol/L).
 To convert mg/dL to mmol/L, multiply by 0.2495.

Carbon Dioxide (“Total C02” OR Bicarbonate):


 Adult 23-29 mmol/L
 child 20-28 mmol/L

Chloride, Serum:
 97-107 mEq/L (SI: 97-107 mmol/L)

Cholesterol:
 Total. Normal. To convert mg/dL to mmol/L, multiply
by 0.02586.
Creatinine Phosphokinase (Kinase) (CP, CPK):
 24-145 mU/mL (SI: 25-145 U/L)

Creatinine, Serum:
 Adult male <1.2 mg/dL (SI: 106 mmol/L)
 Adult female <1.1 mg/dL (SI: 97mmol/L)
 Child 0.5-0.8 mg/dL (SI: 44-71 mmol/L)
 To convert mg/dL to pmol/L, multiply by 88.40

Erythropoietin (EPO):
 5-36 mU (5-36 IU/L)

Fecal Fat:
 2-6 g/d on an 80-100 g/d fat diet.
 72-h collection time. Sudan III stain, random <60
droplets fat/hpf
Ferritin:
 Male 15-200 ng/mL (SI: 15-200 mg/L).
 Female 12-150 ng/mL (SI: 12-150 mg/L)

Glucose:
 Fasting, 70-105 mg/dL (SI: 3.89-5.83 nmol/L). 2 h
postprandial <140 mg/dL (SI: <7.8 nmol/L).
 To convert mg/dL to nmol/L, multiply by 0.05551.

Iron:
 Males 65-175 mg/dL (SI: 11.64-31.33 mmol/L).
 Females 50-170mg/dL (SI: 8.95-30.43 mmol/L).
 To convert mg/dL to mmol/L, multiply by 0.1791.

Iron-Binding Capacity, Total (TIBC):


 250-450 mg/dL (SI: 44.75-80.55 mmol/L)

Lactate Dehydrogenase (LD, LDH):


 Adults <230 U/L, (<3.82 mkat/L).
 Higher levels in childhood.

Magnesium:
 1.6-2.6 mg/dL (SI: 0.80-1.20 mmol/L)

Osmolality, serum:
 278-298 mOsm/kg (SI: 278-298 mmol/kg)

Phosphorus:
 Adult 2.5-4.5 mg/dL (SI: 0.81-1.45 mmol/L).
 Child 4.0-6.0 mg/dL (SI: 1.29-1.95 mmol/L).
 To convert mg/dL to mmol/L, multiply by 0.3229

Potassium, Serum:
 3.5-5 mEq/L (SI: 3.5-5mmol/L)

Sodium, Serum:
 136-145 mmol/L

Uric Acid:
 Males: 3.4-7 mg/dL (SI: 202-416 mmol/L).
 Females: 2.4-6 mg/dL (SI: 143-357 mmol/L).
 To convert mg/dL to mmol/L, multiply by 59.48.

Zinc:
 60-130 mg/dL (SI: 9-20 mmol/L)