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Flashcards in paeds Deck (20)
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1
Q

commonly seen clinical signs of respiratory distress in a newborn

A

Distortion of the chest wall (sternal and rib retraction, recession of intercostal, subcostal and suprasternal spaces)

Pallor

Apnoea

Bradycardia

Lethargy, listlessness, decreased level of consciousness

2
Q

Causes of neonatal respiratory distress (several days after birth)

A

Upper airway obstruction

Bronchiolitis

Pneumonia

Aspiration

Cardiac failure (usually associated with high pulmonary blood flow, VSD, PDA, truncus arteriosus etc; left heart obstructive lesions; coarctation of the aorta; aortic stenosis)

Sepsis

3
Q

factors that predispose neonates to respiratory failure

A

Increased metabolic demand – oxygen consumption twice that of the adult

Structural immaturity of the thoracic cage – ribs short and horizontal, bucket motion is minimal - infant is dependant on diaphragmatic displacement of abdominal contents to increase volume of the thorax any increase in abdominal distension may compromise respiratory function.

Infant airways – small and more prone to obstruction
Immaturity of immune system increasing susceptibility to infection

Immature development of the respiratory system – particularly in premature infants with surfactant deficiency, alveolar instability, reduced lung compliance

Immaturity of respiratory control – immature respiratory centre results in inadequate respiratory drive and can lead to apnoea.

Congenital abnormalities – either respiratory or cardiovascular may lead to early respiratory failure

Perinatal injuries – pneumothorax, neuromuscular including perinatal asphyxia which can result in apnoeas.

4
Q

indications for intubation in three year old with stridor

A
  • Complete or imminent airway obstruction
  • Worsening airway obstruction despite appropriate therapy (eg steroids + nebulised adrenaline in croup)
  • Dangerous reduction in conscious state
  • Uncorrectable hypoxaemia
5
Q

Differentials for bronciolitis

A

Recurrent viral-triggered wheezing
Bacterial pneumonia
Chronic lung disease of ex-prematurity (or some other sort of chonic lung disease)
Foreign body aspiration
Aspiration pneumonia
Congenital heart disease with heart failure
Vascular rings (eg. pulmonary artery slings)

6
Q

Clinical signs of severity in bronchiolitis:

A
Tachypnoea (over 70)
Nasal flaring
Grunting
Subcostal or intercostal recession
Tracheal tug ("suprasternal resession")
Use of accessory muscles
Apnoeic episodes
Hypoxia on pulse oximetry (less than 90%)
7
Q

Risk factors for severe bronchiolitis:

A
Ex prematurity
Low birth weight
Less than 12 weeks old
Bronchopulmonary dysplasia of ex-prematurity
Anatomical defects of the upper airways
Hemodynamically significant congenital heart disease
Immunodeficiency
Neurological disease
Smokers in the household
Crowded households
Attending day-care
Older siblings
Concurrent birth siblings
High altitude
8
Q

Advanced strategies to improve gas exchange in bronchiolitis

A
​Nebulised hypertonic saline 
Nebulised surfactant
Heliox
ECMO
None of these are strongly based in any sociaety recommendations, and sucess is mainly known from case reports
9
Q

Supportive therapies in the management of bronchiolitis:

A

Airway: ​
Assess the need for intuibation (rarely required)

Ventilation:
Just oxygen to begin with
Aim for sats of over 90%
CPAP or HFNP may be the next step of escalation.

Respiratory distress will escalate whenever the child is handled; the key to respiratory success is to minimise handling and to group all routine cares so that the child gets long breaks between distressing events.

Circulation:
​IV maintenance fluids and resuscitation of dehydration
Assessment for any coexisting cardiac disease with TTE

Electrolytes
Watch for SIADH: apparently that is one of the possible complications

Nutrition
​Nasogastric feeding to make up for recent deficit

Antibiotics
​Routine use of IV antibiotics is not indicated
Ribavirin has been trialled, and is also not recommended for routine treatment of RSV
infection but may be considered in select immunocompromised individuals
Palivizumab, a humanized monoclonal antibody (IgG) directed against RSV, may be used in at-risk populations for prevention (eg. premature infants during RSV season).

10
Q

Strategies forbronchiolitis which have been trialled and which clearly do not work:

A

​Nebulised bronchodilators
Montelucast
Corticosteroids (no evidence of benefit, and may even increase the duration of viral shedding)
Chest physiotherapy (probably no benefit)
Caffeine or aminophylline (they were supposed to decrease the risk of apnoeas, but they do not seem to work)
However, it must be mentioned that the trials of all these interventions excluded the “severe” category of patients.

11
Q

Ongoing fluid management in sick child

A

FLuid - add 100 ml of 50% dextrose to 900 ml 0.9% NaCl

Use 2/3 maintenance rate (4,2,1 rule) - could give full rate for 48 hours

Replace losses - calcuate every 4 hours

If low BSL give 2-5mls 10% dextrose

12
Q

% dehydration formula and how to replace

A

replace over 48 hours using maintenance fluid

Formula: Vol = % Dehydration x body weight x 10 (in mls)

13
Q

Bronchiolitis features

A

under 2
upper resp prodrome eg rhinorrhoea
lower resp features eg wheeze and creps
increased resp effort

14
Q

bronchiolitis causesq

A

usually RSV

May also be - rhinovirus, influenza, parainfluenza, adenovirus, coronavirus (sars, mers)

15
Q

Prognostication of drowning

A

30%-50% will die
10% survive with severe neurological sequelae
The rest may recover unremarkably

16
Q

Features which favour non-survival or severe disability following drowning:

A
Apnoea on presentation to ED
Coma (GCS < 8) on presentation to ED
pH < 7.00 
Need for CPR in the ED
CPR for longer than 10 minutes
17
Q

The list of criteria for the diagnosis of simple febrile convulsions:

A

Fever >38.0°
No history of neonatal seizures
No previous unprovoked seizures
No focal neurological features (i.e. generalised seizure)
Tonic-clonic seizure
Occurs after 6 months of age, and before the age of 6
Lasts less than 15 minutes
Occurs only once per episode of febrile illness.

18
Q

Investigations to perform on a very unwell neonate

A
CXR
ECG
Ammonia
Urine amino and organic acids (if can’t be processed, take while acidotic and store  - remmeber inborn errors of metabolism on DDx
Cultures if not done
CMV, HSV PCR
Consider skeletal survey if any suggestion of injury
Cranial ultrasound (widely available)

Echo if available
19
Q

Clinical signs of severe dehydration in infants (>10% loss body weight)

A

2 or more of:

Abnormally sleepy or lethargic.
Sunken eyes.
Drinking poorly or not at all.
Very poor skin turgor; after pinch test the skin fold is visible for longer than 2 seconds.
Weak rapid pulse
Cool or blue extremities
Hypotension
Rapid breathing
Sunken anterior fontanelle.
20
Q

Clinical signs of mild to moderate dehydration in infants (5-6% or 7-10% wt loss)

A

2 or more of:

Restlessness or irritability.
Sunken eyes (also ask the parent).
Thirsty and drinks eagerly.
Poor skin turgor; after pinch test the skin fold is visible for less than 2 seconds.