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EXPANDED PROGRAM ON IMMUNIZATION
VACCINE AGE DOSE # ROUTE SITE INTERVALBCG-1 Birth
or 6 wks0.05mL
(NB)0.1mL (older)
1 ID R-Deltoid
DPT 6 wks 0.5mL 3 IM Upper Outer thigh
OPV 6 wks 2 drops 3 PO Mouth 4 wksHEPA B 6 wks 0.5mL 3 IM Antero-
lateral thigh
4 wks
MEASLES 9 mos 0.5mL 1 SC Outer upper arm
4 wks
BCG-2 School entry 0.1mL 1 ID L-Deltoid
TetToxoid Childbearing women
0.5mL 3 IM Deltoid 1 mo then6-12 mos
ADVERSE REACTIONS FROM VACCINES
BCG 1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis
DPT 1. Fever, local soreness2. Convulsions, encephalitis / encephalopathy, permanent brain damage
OPV Paralytic PolioHEPA B Local sorenessMEASLES 1. Fever & mild rash
2. Convulsions, encephalitis / encephalopathy, SSPE, death
ACTIVE PASSIVEBCG DiphtheriaDPT TetanusOPV Tetanus Ig
Hep B Measles IgMeasles Rabies (HRIg)
Hib Hep A IgMMR Hep B ig
Tetanus Toxoid Rubella IgVaricella
BODY TEMPERATURE
Subnormal <36.6°CNormal 37.4°CSubfebrile 35.7 – 38.0°CFever 38.0°CHigh fever >39.5°CHyperpyrexia >42.0°C
AGE HR (bpm) BP (mmHg) RR (cpm)
Preterm 120-170 55-75/35-45 40-70Term 120-160 65-85/45-55 30-600-3 mo 100-150 65-85/45-55 35-553-6 mo 90-120 70-90/50-65 30-456-12 mo 80-120 80-100/55-65 25-401-3 yrs 70-110 90-105/55-70 20-303-6 yrs 65-110 95-110/60-75 20-256-12 yrs 60-95 100-120/60-75 14-2212-17 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
BMI
Asian CaucasianUnderweight <18.5 <18.5Normal 18.5 – 22.9 18.5 – 24.9Overweight ≥ 23.0 25 – 29.9at risk 23 – 24.9Obese I 25 – 29.9 30 – 39.9Obese II ≥ 30 >40
ABG pH: 7.35-7.45 HCO3: 22-26mEq/LpCO2: 35-45 B.E.: +/- 2mEq/LpO2: 80-100 O2 sat: 97%
NORMAL LABORATORY VALUES
NB Infant Child AdoleRBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2
F: 4.2-5.4WBC 9-30,000 6-17,500 5-10,000 6-10,000PMNs 61% 61% 60% 60%Lymph 31% 32% 30% 30%Hgb 14-24 11-20 11-16 M: 14-18
F: 12-16Hct 44-64% 35-49 31-46 M: 40-54
F: 37-47Platelets 140-300 200-423 150-450 150-450Ret 2.6-6.5 0.5-3.1 0-2 0-2
COUNT (%)
BT 1-5 min 1-6 1-6 1-6CT 5-8 min 5-8 5-8 5-8PTT 12-20sec 12-14 12-14 12-14
ANTHROPOMETRIC MEASUREMENTS
IDEAL BODY WEIGHT
Age Kilograms PoundsAt Birth 3kg (Fil)
3.35kg (Cau)7
3-12 mo
Age (mo) + 9 / 2 Age (mo) + 10 (F)Age (mo) + 11 (C)
1-6 y Age (y) x 2 + 8 Age (y) x 5 + 177-12 y Age (y) x 7 – 5 / 2 Age (y) x 7 + 5
Given Birth Weight:Age Using Birth Weight in Grams
< 6 mo Age (mo) x 600 + birth weight (gm)6-12 mo Age (mo) x 500 + birth weight (gm)
Expected Body Weight (EBW):Term Age in days – 10 x 20 + Birth Weight
Pre-Term Age in days – 14 x 15 + Birth Weight
Age of Infant Ideal Weight4-5 months 2 x Birth Weight
1 year 3 x Birth Weight2 years 4 x Birth Weight3 years 5 x Birth Weight5 years 6 x Birth Weight7 years 7 x Birth Weight10 years 10 x Birth Weight
LENGTH / HEIGHT(50 cm)
Age Centimeters InchesAt Birth 50 20
1 y 75 302-12 mo Age x 6 + 77 Age x 2.5 + 30
Age Gain in 1st Year is ~ 25cm0-3 mo + 9 cm 3 cm per mo3-6 mo + 8 cm 2.67 per mo6-9 mo + 5 cm 1.6 cm per mo
9-12 mo + 3 cm 1 cm per mo
HEAD CIRCUMFERENCE(33-38 cms)
Age Inches CentimetersAt Birth 35 cm (13.8 in)< 4 mo + 2 in
(1/2 inches / mo)+ 5.08cm
(1.27cm / mo)5-12 mo + 2 in
(1/4 inches / mo)+ 5.08cm
(0.635cm / mo)1-2 yrs + 1 inch 2.54 cm3-5 yrs + 1.5 in
(1/2 inches / year)+ 3.81cm
(1.27cm / mo)6-20 yrs + 1.5 in
(1/2 inches / year)+ 3.81cm
(1.27cm / mo)
Age Transverse-AP Diameter ratio
Inches
At Birth 1.0 Transverse = AP1 y 1.25 Transverse > AP6 y 1.35 Transverse >>> AP
FONTANELS
Appropriate size at birth: 2 x 2 cm (anterior)Closes at: Anterior = 18 months, or as early
as 9-12 monthsPosterior = 6 – 8 weeks or
2 – 4 months
THORACIC INDEX
TI = transverse chest diameter AP diameter
Birth : 1.01 year : 1.256 years : 1.35
APGAR
0 1 2
ABlue / Pale
Pink body/ Blue extremities
Completely pink
P Absent Slow (<100) > 100
G(-)
ResponseGrimaces
Coughs, Sneezes,
Cries
A(-)
MovementSome flexion /
extensionActive
movement
R Absent Slow / IrregularGood,
strong cry
8 – 10: Normal4 – 7: Mild / Moderate Asphyxia0 – 3: Severe asphyxia
GCS
Function Infants/Young OlderEye Opening
4- Spontaneous3- To speech2- To pain1- None
SpontaneousTo speechTo painNone
Verbal 5- Appropriate4- Inconsolable3- Irritable2- Moans1- None
OrientedConfusedInappropriateIncomprehensibleNone
Motor 6- Spontaneous5- Localize pain4- Withdraw3- Flexion2- Extension1- None
SpontaneousLocalize painWithdrawFlexionExtensionNone
H.E.A.D.S.S.S.
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.
◦ F luids◦ R espiration◦ I nfection◦ C ardiac◦ H ematologic◦ M etabolic◦ O utput & Input [cc/kg/h] N: 1-2◦ N euro ◦ D iet
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?
NUTRITION
AGE WT. CAL CHON0-5 mo 3-6 115 3.5
8-11 mo 7-9 110 3.01-2 y 10-12 110 2.53-6 y 14-18 90-100 2.07-9 y 22-24 80-90 1.5
10-12 y 28-32 70-80 1.513-15 y 36-44 55-65 1.516-19 y 48-55 45-50 1.2
TCR β = Wt 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
1:1 1:2Alacta BonnaEnfalac Nursoy
Lactogen PromilLactum S-26
Nan SimilacNestogen SMA
NutraminogenPelargonProsobee
THE SEVEN HABITS OFHIGHLY EFFECTIVE PEOPLE
by Stephen R. Covey
Habit 1: Be ProactiveHabit 2: Begin with the end in mind Habit 3: Put First Things FirstHabit 4: Think Win-WinHabit 5: Seek first to understand and
then to be understood Habit 6: SynergizeHabit 7: Sharpen the saw
EXPECTED LA SALLIAN GRADUATE ATTRIBUTES
(ELGA)
1. Competent & safe physicians2. Ethical & socially responsible
Doctors / practitioners3. Reflective lifelong learners4. Effective communicators5. Efficient & innovative managers
TREATMENT PLAN B
Recommended amount of ORS over 4 hour period
Age up to: 4 mo – 4 mo 12 mo – 12 mo 2 yrs – 2 yrs 5 yrsWt: <6kg 6-9.9kg 10-11.9kg 2-19kg(mL) 200-400 400-700 700-900 900-1400
◦ Use child’s age only when weight is not known◦ Approximate amount of ORS (mL) CHILDS WT (kg) x 25
◦ if the child wants more ORS than shown, give more◦ give frequent small sips from a cup◦ if the child vomits, wait for 10 min then resume◦ continue breastfeeding whenever the child wants
AFTER 4 HOURS◦ reassess the child & classify dehydration status◦ select the appropriate plan to continue treatment◦ begin feeding the child while at the clinic
DIARRHEA ◦ Chronic : >14 days, non-infectious causes◦ Persistent : >14 days, infectious cause
◦ ORS vol. after each loose stool 1 day
<24 mo 5-100mL 500mL 2-10 y.o. 100-200mL 1000mL >10 y.o. As much as wanted 2000mL
For severe dehydration / WHO hydration(fluid: PLR 100cc/kg)
Age 30mL/kg 75mL/kg <12 1H 5H >12 30 mins 2 ½ H
Patient in SHOCK
◦ 20-30cc/kg IV fast drip◦ but in infants 10cc/kg IV (repeat if not stable)◦ If responsive & stable 75/kg x 4-6 hours
ACUTE DIARRHEA (at least 3x BM in 24 hrs)
4 Major Mechanisms
1. Poorly absorbed osmotically active substances in lumen
2. Intestinal ion secretion (increased) or decreased absorption
3. Outpouring into the lumen of blood, mucus4. Derangement of intestinal motility
Rotaviral AGE (vomiting first then diarrhea)
Ingestion of rotavirus ► rotavirus in intestinal villi►destruction of villi
(secretory diarrhea ▼absorption ▲ secretion) ► AGE
Assessment of dehydration (Skin Pinch Test)
◦ (+) if > 2 seconds◦ no dehydration if skin tenting goes back
immediately
ETIOLOGY of AGE
Bacteria VirusesAeromonas AstrovirusesBacillus cereus Caloviruses Campylobacter jejuni Norovirus Clostridium perfringens Enteric AdenovirusClostridium difficile RotavirusEscherichia coli CytomegalovirusPlesiomonas shigelbides Herpes simplex virusSalmonellaShigella Staphylococcus aureus Vibrio cholerae 01 & 0139Vibrio parahaemolyticus Yersinia enterocolitica
ParasitesBalantidium coliBlastocyctis hominis CryptosporidiumGiardia lamblia
Amoeba Metronidazole Ascariasis Al/mebendazole Cholera Tetracyline Shigella TMP/SMX (Cotri) Salmonella Chloramphenicol
TREATMENT PLAN A
4 Rules of Home Treatment
1. 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)
clean water
How much fluid to be given in addition to the usual fluid intake?
Up to 2 years: 50-100 mL after each loose stool
2 years or more: 140-200 mL
:- give frequent small sips from a cup :- if the child vomits, wait for 10 min then resume :- continue giving extra fluids until diarrhea stops
2. Give Zinc supplements
Up to 6 mo: 1 half tab per day for 10-14 days 6 months or more: 1 tab or 20mg OD x 10-14 days
3. Continue feeding4. Know when to return
TREATMENT PLAN C
Treat severe dehydration QUICKLY!
1. Start IV fluid immediately2. If the child can drink, give ORS by mouth while the
IV drip is being set up3. Give 100mL/kg Lactated Ringer’s solution
AgeFirst give Then give
30mL/kg in: 70mL/kg in:Infants
(<12mo)1 hour* 5 hours
Children(12mo-5yrs)
30 min* 2 ½ hours
Repeat once if radial pulse is very weak or not detectable
◦ reassess the child every 15-30 min.if dehydration is not improving,give IV fluid more rapidly
◦ also give ORS (~5mL/kg/hr) as soon as the child can drink [usually after 3-4 hours in infants; 1-2 hours in children]
◦ reassess after 6 hrs (infant) & 3 hrs (child)
SMR GIRLSStage Pubic Hair Breasts
1 Preadolescent Preadolescent
2Sparse, lightly pigmented, straight,
medial border of labiaBreast & papilla elevated, as small mound, areola diameter increased
3 Darker, beginning to curl, ▲amountBreast & areola enlarged, no contour
separation
4Course, curly, abundant but amount <
adultAreola & papilla formed secondary
mound
5Adult, feminine triangle, spread to
medial surface of thighMature, nipple projects, areola part of
general breast contour
SMR BOYSStage Pubic Hair Penis Testes
1 None Preadolescent Preadolescent
2Scanty, long slightly
pigmentedSlightly enlargement
Enlarged scrotum, pink texture altered
3Darker, starts to curl, small
amountLonger Larger
4Resembles adult type but less in quantity, course,
curly
Larger, glans & breadth ▲ in size
Larger, scrotum dark
5Adult distribution, spread to medial surface of thigh
Adult size Adult size
ORS
• 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 adults.
Glucose:100mmol/L
Cl: 50mmol/L
Gluconate:5mmol/L
Na: 60 mol/L
Mg: 5mmol/L
K: 20 mmol/L
Citrate:10 mmol/L
• Hydrite-: 2 tab in 200ml water or 10sachets in 1L water
Glucose:111mmol/L
Cl: 80mmol/L
Glucose:11mml/L
Na: 90 mmol/L
HCO3: 5mmol/L
Na:90 mmol/L
K:20 mmol/L
K:20 mmol/L
• Pedialyte 45 0r 90-: prevention of DHN & to maintain normal fluidelectrolyte balance in mild to moderate dehydration.
Glucose 45mEq Glucose 90mEq Na: 20mEq Na: 20mEq K: 35mEq K: 80mEq
Citrate: 30mEq Citrate: 30mEqDextrose: 20g Dextrose: 25g
• Pedialyte mild 30-: to supplement fluid & electrolyte loss due to active play, prolonged exposure, hot and humid environment
Glucose: 30mEq Mg: 4mEqNa: 20mEq lactate: 20mEqK: 30mEq Ca: 4mEq
Energy: 20kcal/ 100ml
ETIOLOGY OF PNEUMONIA
Bacterial- Streptococcus pneumoniae - Group B streptococci (neonates)- Group A streptococci- Mycoplasma pnemoniae (adolescents)- Chlamydia trachomatis (infants)- Mixed anearobes (aspiration pneumonia)- Gram negative enteric (nosocomial pneumonia)
Viral - Respiratory syncitial virus- Parainfluenza type 1-3 (Croup)- Influenza types A, B- Adenovirus- Metapneumovirus
Fungal - Histoplasma capsulatum (bird, bat contact)- Cryptococcus neoformans (bird contact)- Aspergillus sp. (immunosuppressed)- Mucormycosis (immunosuppressed)- Coccidioides immitis - Blastomyces dermatitides - Pneumocystis carinii (immunosuppressed, HIV, steroids)
LUDAN’S METHOD (HYDRATION THERAPY)
MILD DEHYDRATION
MODERATE DEHYRATION
SEVERE DEHYDRATION
< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg
D5 0.3% in6-8 hours
1st hr: ¼ Plain LRNext 5-7 hrs:¾ D5 0.3% in
5-7 hours
1st hr: ⅓ Plain LR Next 5-7 hrs:⅔ D5 0.3% in
5-7 hours
HOLIDAY-SEGAR METHOD (MAINTENANCE)
WEIGHT TOTAL FLUID REQUIREMENT0 - 10 kg 100 mL / kg11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg]> 20 kg 1500 + [ 20 for each kg in excess of 20 kg]
NOTE: Computed Value is in mL/day Ex. 25kg child Answer: 1500 + [100] = 1600cc/day
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ATYPICAL PNEUMONIA
-: extrpulmonary manifestations-: low grade fever-: patchy diffuse infiltrates-: poor response to Penicillin-: negative sputum gram stain
Etiologic Agents Grouped by Age
> Neonates (<1mo) - GBS - E. coli - other gram (-) bacilli - Streptococcus pneumoniae - Haemophilus influenza (Type B)
> 1-3 months * Febrile pneumonia - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenza (Type B) * Afebrile pneumonia - Chlamydia trachomatis - Mycoplasma homilis - CMV
> 3-12 mo - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus
> 2-5 yrs - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus
> 2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus
Dengue Shock Syndrome
Manifestations of DHF plus signs of circulatory failure1. rapid & weak pulse2. narrow pulse pressure (<20mmHg)3. hypotension for age4. cold, clammy skin & irritability / restlessness
DANGER SIGNS OF DHF
1. abdominal pain (intense & sustained) 2. persistent vomiting 3. abrupt change from fever to hypothermia with sweating 4. restlessness or somnolence
Grading of Dengue Hemorrhagic Fever
DENGUE
> MOT: mosquito bite (man as reservior)
> Vector: Aedes aegypti
> Factors affecting transmission: - breeding sites, high human population density, mobile viremic human beings
> Age incidence peaks at 4-6 yrs
> Incubation period: 4-6 days
> Serotypes: - Type 2 – most common - Types 1& 3 - Type 4– least common but most severe
> Main pathophysiologic changes: a. increase in vascular permeability ▼ extravasation of plasma - hemoconcentration - 3rd spacing of fluids b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy
Dengue Fever Syndrome (DFS)
Biphasic fever (2-7 days) with 2 or more of the ff:
1. headache2. myalgia or arthralgia 3. retroorbital pain4. hemorrhagic manifestations [petechiae, purpura, (+) torniquet test]5. leukopenia
Dengue Hemorrhagic Fever (DHF) 1. fever, persistently high grade (2-7 days)2. hemorrhagic manifestations - (+) torniquet test - petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis 3. Thrombocytopenia (< 100,000/mm3)4. Hemoconcentration - hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following volume replacement - signs of plasma leakage [pleural effusion, ascites, hypoproteinemia]
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MANAGEMENT OF DENGUE
A. Vital Signs and Laboratory Monitoring Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)
MANAGEMENT OF HEMORRHAGE
Torniquet Test: SBP + DBP = mean BP for 5 mins. 2
if ≥20 petechial rash per sq. inch on antecubital fossa (+) test
Herman’s Rash: - usually appears after fever lysed - initially appears on the lower extremities- not a common finding among dengue patients- “an island of white in an ocean of red”
Recommended Guidelines for Transfusion:
Transfuse:- PC < 100,000 with signs of bleeding- PC < 20,000 even if asymptomatic- use FFP if without overt bleeding- FWB in cases with overt bleeding or signs of hypovolemia
> if PT & PTT are abnormal: FFP> if PTT only: cryprecipitate
3-7cc/kg/hr depending on the Hct (1st no.) level (D5LR)10-20cc/kg fast drip PLR - hypotension, narrow pulse pressure fair pulse
Leukopenia in dengue: probable etiology isPseudomonas
therefore: give Meropenem or Ceftazidime
URINARY TRACT INFECTION
Suggestive UTI:- Pyuria: WBC ≥ 5/HPF or 10mm3
- Absence of pyuria doesn’t rule out UTI- Pyuria can be present w/o UTI
Presumptive UTI:- (-) urine culture- lower colony counts may be due to: * overhydration * recent bladder emptying * previous antibiotic intake
Proven or Confirmed UTI:- (+) urine culture ≥ 100,000 cfu/mL urine of a single organism- multiple organisms in culture may indicate a contaminated sample
ACUTE GLOMERULONEPHRITIS
Complications of AGN- CHF 2° to fluid overload- HPN encephalopathy- ARF due to ê GFR
STAGES of AGN- Oliguric phase [7-10days] – complications sets in- Diuretic phase [7-10days] – recovery starts- Convalescent phase [7-10days] – patients are
usually sent home
Prognosis - Gross hematuria 2-3 weeks- Proteinuria 3-6 weeks- ▼C3 8-12 weeks- microscopic hematuria 6-12 mo or
1-2 years- HPN 4-6 weeks
> Hyperkalemia may be seen due to Na+ retention> Ca++ decreases in PSAGN> ▲ in ASO titer - normal within 2 weeks - peaks after 2 weeks - more pronounced in pharyngeal infection than in cutaneous
RHEUMATIC FEVER
JONES CRITERIA:
A. Major Manifestations - Carditis (50-60%) - Polyarthritis (70%) - Chorea (15-20%) - Erythema Marginatum (3%) - Subcutaneous Nodules (1%)
B. Minor Manifestations - Arthralgia - Fever - Laboratory Findings of: ▲ Acute Phase Reactants (ESR / CRP) Prolonged PR interval
C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection - (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test
TREATMENT OF RHEUMATIC FEVER
A. Antibiotic Therapy - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin
*** NOTE: Sumapen = Oral Penicillin!
B. Anti-Inflammatory Therapy
1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks
2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days
PREVENTON
A. Primary Prevention
- 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin
B. Secondary Prevention
C. Duration of Chemoprophylaxis
KAWASAKI DISEASE CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI(ALL SHOULD BE PRESENT)
A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation
“High Grade Fever of at least 5 days” DOES NOT Respond to any kind of Antibiotic!
B) Presence of 4 of the 5 Criteria1. Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%) 2. Changes of the Lips and Oral Cavity (At least ONE) 3. Changes of the Extremities (At least ONE) 4. Polymorphous Exanthem (92%) 5. Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%) HARADA Criteria- used to determine whether IVIg should be given- assessed within 9 days from onset of illness
1. WBC > 12,0002. PC <350,0003. CRP > 3+4. Hct <35%5. Albumin <3.5 g/dL 6. Age 12 months7. Gender: male
• IVIg is given if ≥ 4 of 7 are fulfilled• If < 4 with continuing acute symptoms,
risk score must be reassessed daily
TREATMENT
Currently Recommended Protocol:
A. IV-Immunoglobulin
2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day
Regimen with respect to Amelioration of Inflammation as measured by days of
Fever, ESR, CRP, Platelet Count, Hgb, and Albumin
NOTE: There is a TIME FRAME of 10 days
B. Aspirin
HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG
THENReduced to Low Dose Aspirin (3-5mg/kg/day)
ANDContinued until Cardiac Evaluation COMPLETED
(approximately 1-2 months AFTER Onset of Disease)
TYPES OF SEIZURES
A. Partial Seizures (Focal / Local)– Simple Partial– Complex Partial (Partial Seizure +
Impaired Consciousness)– Partial Seizures evolving to Tonic-Clonic
Convulsion B. Generalized Seizures
– Absence (Petit mal)– Myoclonic – Clonic – Tonic– Tonic-Clonic – Atonic
SIMPLE FEBRILE SEIZUREvs.
COMPLEX FEBRILE SEIZURE
Febrile Seizure: “A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”
CLASSIFICATION BY CAUSE
A. Acute Symptomatic(shortly after an acute insult)– Infection– Hypoglycemia, low sodium, low calcium– Head trauma– Toxic ingestion
B. Remote Symptomatic
– Pre-existing brain abnormality or insult– Brain injury (head trauma, low oxygen)– Meningitis– Stroke– Tumor– Developmental brain abnormality
C. Idiopathic
– No history of preceding insult– Likely “genetic” component
SEIZURES
> Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronousdischarges of neurons
> Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause
> Status epilepticus: >30min or back-to-backw/o return to baseline
> Etiology:- V ascular : AVM, stroke, hemorrhage- I nfections : meningitis, encephalitis- T raumatic :- A utoimmune : SLE, vasculitis, ADEM- M etabolic : electrolyte imbalance- I diopathic : “idiopathic epilepsy”- N eoplastic : space occupying lesion- S tructural : cortical malformation,
prior stroke - S yndrome : genetic disorder
SIMPLE FEBRILE SEIZURE
A. Criteria for an SFS– < 15 minutes– Generalized-tonic-clonic – Fever > 100.4 rectal to
101 F (38 to 38.4 C)– No recurrence in 24 hours– No post-ictal neuro
abnormalities (e.g. Todd’s paresis)– Most common 6 months to
5 years– Normal development– No CNS infection or prior
afebrile seizures B. Risk Factors
– Febrile seizure in 1st / 2nd degree relative
– Neonatal nursery stay of >30 days
– Developmental delay– Height of temperature
C. Risk Factors for Epilepsy
(2 to 10% will go on to have epilepsy)– Developmental delay– Complex FS (possibly > 1
complex feature)– 5% > 30 mins => _ of all
childhood status– Family History of Epilepsy– Duration of fever
BRONCHIAL ASTHMA (GINA GUIDELINES)
Controlled Partly Controlled UncontrolledDay symptoms
none > 2x per wk
3 or more symptoms of Partly Controlled Asthma in any week
Limitation of activities
none any
Nocturnal Sx (awakening)
none any
Need for reliever
< 2x per wk > 2x per wk
Lung function
normal < 80%
Exacerbation none > 1x per yr 1x / week
TUBERCULOSIS
A. Pulmonary TB– fully susceptible M. tuberculosis, – no history of previous anti-TB drugs– low local persistence of primary resistance to
Isoniazid (H)
☤ 2HRZ OD then 4HR OD or 3x/wk DOT
– Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary)
– previous anti-TB use– close contact w/ resistant source case or living
in high areas w/ high pulmonary resistance to H.
–☤ 2HRZ + E/S
OD, then 4 HR + E/S OD or 3x/week DOT
B. Extrapulmonary TB– Same in PTB
– For severe life threatening disease (e.g. miliary, meningitis, bone, etc)
☤ 2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT
RESPIRATORY DISTRESS SYNDROME(Hyaline Membrane Disease)
o Male, preterm, low BW, maternal DM, & perinatal asphyxia
o Corticosteroids:• most successful method to induce fetal lung
maturation• Administered 24-48 hours before delivery
decrease incidence of RDS• Most effective before 34 weeks AOG
o Microscopically: diffuse atelectasis, eosinophilic membrane
Pathophysiology:
1. Impaired/delayed surfactant synthesis & secretion
2. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance
3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis5. Pulmonary vasoconstriction6. Impaired endothelial &epithelial integrity7. Proteinous exudates8. RDS
NEWBORN RESUSCITATION
AIRWAY: open & clear Positioning Suctioning Endotracheal intubation (if necessary)
BREATHING is spontaneous or assisted Tactile stimulation (drying, rubbing) Positive-pressure ventilation
CIRCULATION of oxygenated blood is adequate Chest compressions Medication and volume expansion
RESUSCITAION MEDICATIONS
Atropine 0.02 ml/k IM, IV, ETBicarbonate 1-2 meq/k
Calcium 10 mg elem Ca/k slow IVCalcium chloride 0.33/k (27 mg Ca/cc)
Calcium gluconate 1 cc/k (9 mg Ca/cc)
Dextrose1g/k = 2 cc/k D50 4 cc/k D25
Epinephrine 0.01 cc/k IV, ET
UMBILICAL CATHERIZATION
Indications• Vascular access (UV)• Blood Pressure (UA) and blood gas monitoring in
critically ill infants
Complications• Infection• Bleeding• Hemorrhage• Perforation of vessel• Thrombosis w/ distal embolization • Ischemia or infarction of lower extremities, bowel
or kidney• Arrhythmia• Air embolus
Cautions• Never for:– Omphalitis – Peritonitis
• Contraindicated in– NEC– Intestinal hypoperfusion
Line Placement• Arterial line• Low line– Tip lie above the bifurcation between L3 & L5
• High line– Tip is above the diaphram between T6 & T9
Clinical Features:
1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting
2. Pallor – from anemia, peripheral vasoconstriction
3. Onset – within 6 hours of life Peak severity – 2-3 days Recovery – 72 hours
Retractions:o Due to (-) intrapleural pressure produced by
interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall
Nasal flaring:o Due to contraction of alae nasi muscles leading to
marked reduction in nasal resistance
Grunting:o Expiration through partially closed vocal cords
• Initial expiration: glottis closedàlungs w/ gasàinc. transpulmo P w/o airflow
• Last part of expiration: gas expelled against partially closed cords
Cyanosis: o Central – tongue & mnucosa (imp. Indicator of
impaired gas exchange); depends on total amount of desaturated Hgb
Cathether length• Standardize Graph– Perpedicular line from the tip of the shoulder to
the umbilicus• Measure length from Xiphoid to umbilicus and add
0.5 to 1cm.• Birth weight regression formula– Low line : UA catheter in cm = BW + 7– High line : UA catheter = [3xBW] + 9– UV catheter length = [0.5xhigh line] + 1
Procedure• Determine the length of the catheter• Restrain infant and prep the area using sterile
technique• Flush catheter with sterile saline solution• Place umbilical tape around the cord. Cut cord
about 1.5-2cm from the skin.• Identify the blood vessels.
(1thin=vein, 2thick=artery)• Grasp the catheter 1cm from the tip. Insert into the
vein, aiming toward the feet. • Secure the catheter• Observe for possible complications
BILIRUBIN
PRETERM:mg/dl mmol/L
0-1 hr 1-6 17-1001-2 d 6-8 100-1403-5 d 10-12 170-200
TERMmg/dl mmol/L
0-1 hr 2-6 34-1001-2 d 6-7 100-1203-5 d 4-12 70-2001 mo <1 <17
KRAMERS CLASSIFICATION OF JAUNDICE
ZONE JAUNDICESERUM
BILIRUBINI Head & neck 6-8
IIUpper trunk to umbilicus
9-12
IIILower trunk
to thigh12-16
IVArms, legs,
below15
V Hands & feet 15