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IN CHILDREN
Case 1
• Girl, 6 months
• Previous healthy
• History
– Start with coryza since 2 days
– Now since 1 day cough and wheeze
Physical exam
• Body weight 6 kg
• Temp: 38.2 °C, Respiratory rate 50-60/min
• No chest indrawing
• No nasal flaring
• Auscultation
– Some crackles
– Expiratory wheezing
Question
The most likely diagnosis is
5. Only A is true
6. Only B is true
7. A and B are true
8. A and B are false
Intra-thoracal obstruction
+
+ + + +
- + + +
- Ptr < Ppl
- - - +
- + +
- Ptr > Ppl
+
Ptr > Ppl
- -
- Expiration
-
-
Inspiration
Extra-thoracal obstruction
+ Ptr > Patm
-
- +
- +
+ +
- -
Expiration
-
-
Inspiration
Question
A. Expiratory wheezing indicates a lower intra-thoracal
airway obstruction.
Asthma, bronchiolitis
• Only A is true
• Only B is true
• A and B are true
• A and B are false
Case 2
• Boy, 4 yrs old
5. A is true
6. B is true
7. A and B are true
8. A and B are false
Question
A. Respiratory rate of 55/min is normal in children
5. A is true
6. B is true
7. A and B are true
8. A and B are false
Normal values vital signs children
Age Pulse rate Bloodpressure Resp. rate
Note 1: normal pulse rate in case of fever: for every degree temperature
above 37.5 increase pulse rate with 10/min
• Differential diagnosis
– Bronchitis
– Bronchiolitis
– Pneumonia
• Treatment
– Amoxicillin 125mg tds
Question
Among the most frequent bacterial causes
of acute respiratory tract infections in
children are:
1. Streptococcus pneumoniae
2. Haemophilus Influenzae
3. Staphylococcus Aureus
4. All of the above
Semin Pediatr Infect Dis 2005;16:84-92
MSFH Guidelines respiratory tract
infection
Chest indrawing
No Yes
No Yes
2 m-1y: >50/min
1-5 y: >40/min
Pneumonia
Question
A. Mortality rate due to pneumonia decreases when
antibiotics are given promptly
7. A is true
8. B is true
9. A and B are true
10. A and B are false
Meta-analysis of intervention trials on case-management of
pneumonia in community settings
Sazawal et al. Lancet 1992; 340: 528 33
• Results:
35% reduction in mortality rate <5 years of life.
Case continued
History/
Mother returns to the clinic with the boy after
one day because of no improvement
Physical Exam/
Temp 39 °C, resp rate: 50/min, pulse rate 150/min
Chest retractions
Lips and tongue cyanotic
Question
There are 2 forms of cyanosis:
central cyanosis and peripheral cyanosis
4. Micro-organism resistant
5. Not taking amoxicillin appropriately
6. Dosage of amoxicillin
• Streptococcal resistance against β-lactam
antibiotics occurs through β-lactamase production
6. A is true
7. B is true
8. A and B are true
9. A and B are false
Resistance against β-lactam antibiotics
• Streptococci:
– change in Penicillin Binding Protein
– In general this is dose dependent
• H Influenzae
– β-lactamase production
Drug resistance among S pneumoniae in
SE Asia
• Girl, 3 yrs
• Previous healthy
• Since 4 days coryza and skin rash
• Distributive shock
• Hypovolaemic shock
Imminent shock
compensation mechanisms
1. Increase of cardiac output:
Increase of pulse rate in children
Case 1, ♂ 2 y Case 2, ♀ 3 y
• Intervention
– ‘Aggressive’ early volume expansion vs ‘normal’ volume expansion
Early goal directed therapy
consequences for MSFH setting
Before sending to hospital:
1. 20 ml/kg in 30 minutes
2. 5 ml/kg in 2 h