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Clinical Protocol in Pediatrics, 2012
Clinical Protocol in Pediatrics, 2012
in Pediatrics
Jaydeep Choudhury
Assistant Professor
Department of Pediatrics
Institute of Child Health
Kolkata, West Bengal, India
Jayanta Bandyopadhyay
Senior Consultant (Pediatrician)
Durgapur, West Bengal, India
Former Fellow, Pediatric Cardiac Critical Care
Madras Medical Mission
Chennai, Tamil Nadu, India
Senior Registrar, Pediatric Emergency Medicine
Mater Childrens Hospital
Brisbane, Australia
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
2012, Jaypee Brothers Medical Publishers
All rights reserved. No part of this book may be reproduced in any form or by any means
without the prior permission of the publisher.
Inquiries for bulk sales may be solicited at: [email protected]
This book has been published in good faith that the contents provided by the authors
contained herein are original, and is intended for educational purposes only. While every
effort is made to ensure accuracy of information, the publisher and the authors specifically
disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or
application of any of the contents of this work. If not specifically stated, all figures and
tables are courtesy of the authors. Where appropriate, the readers should consult with a
specialist or contact the manufacturer of the drug or device. The publishers and authors
have no financial interest in any procedure or product mentioned in this book.
Publisher: Jitendar P Vij
Publishing Director: Tarun Duneja
Cover Design: Seema Dogra
Clinical Protocol in Pediatrics
First Edition : 2012
ISBN 978-93-5025-511-7
Printed at
PREFACE
Pediatric emergency is a demanding situation which requires immediate decisionmaking. Clinical Protocol in Pediatrics is an endeavor towards building up such an
interesting field of pediatrics wherein the first few golden moments at
presentation to emergency department, a rational, stepwise and correct approach
can not only save the child but also reduce the morbidity to a minimal.
Working in a busy emergency is often stressful and tiresome even for a skilled
doctor with sound knowledge. Going through textbook and descriptive text
may be time-consuming and mind-boggling too. We need at-a-glance format
which can be accessed by emergency physicians, emergency fellows, trainees,
pediatric postgraduates and even practicing pediatricians. This book focuses on
a stepwise approach to common pediatric emergency situations which are
presented in a ready-to-use format.
The book deals with ideas which can be practised in any reasonably good
hospital set-up. It also covers all emergency situations that can be dealt with
both by emergency physicians and pediatricians.
It was an absolute pleasure for us writing this book. We are indebted to our
alma mater The Child Trust Hospital, Chennai, Tamil Nadu, India, where during
our postgraduation, we used to encounter innumerable cases during our long
hours in the emergency room. Perhaps, it was the driving force for this venture.
We are also indebted Dr Robyn Brady, Deputy Director, Pediatric Emergency
Department, Mater Childrens Hospital, Brisbane, Australia, for his impetus
and support.
A supportive family is the backbone of any work. We are fortunate to have
understanding parents, wives and children.
We express our sincere gratitude to Mr Tarun Duneja (Director-Publishing),
Mr Tarun Vij (Director-Pharma), Ms Samina Khan, Mr KK Raman (Production
Manager), and their team in New Delhi, India and Mr Sabyasachi Hazra (Kolkata
Branch), M/s Jaypee Brothers Medical Publisher Pvt Ltd, New Delhi, India, for
their whole-hearted effort and cooperation.
We are open to suggestions and criticisms. Feel free to mail us at
[email protected] and [email protected].
Jaydeep Choudhury
Jayanta Bandyopadhyay
CONTENTS
1. Approach to a Child in Pediatric Emergency Department _ 1
2. Cardiopulmonary Resuscitation ______________________ 3
3. Shock ___________________________________________ 5
4. Coma ___________________________________________ 6
5. Anaphylaxis ______________________________________ 9
6. Oxygen Administration ___________________________ 11
7. Fluid and Electrolyte Balance _______________________ 12
8. Blood Component Transfusion _____________________ 14
9. Chest Tube Drainage and Needle Thoracocentesis ______ 19
10. Prolonged Neonatal Jaundice _______________________ 20
11. Neonatal Collapse ________________________________ 21
12. Respiratory Distress and Noisy Breathing _____________ 22
13. Croup _________________________________________ 23
14. Acute Epiglottitis ________________________________ 25
15. Bronchiolitis ____________________________________ 26
16. Acute Severe Asthma _____________________________ 27
17. Cyanotic Spell ___________________________________ 28
18. Heart Failure ____________________________________ 29
vi
Contents
vii
Approach to a Child in
Pediatric Emergency
Department
2.
3.
4.
5.
6.
TABLE 1.3: Normal weight, respiratory and heart rate in children of different age groups
Age
Birth
3 months
6 months
1 year
2 years
4 years
6 years
8 years
10 years
12 years
14 years
Weight (kg)
RR / min
HR / min
2.5-3.5
6
8
10
12
15
20
25
30
40
50
40-60
30-50
30-50
30-40
20-30
20
16
16
16
16
16
100-160
100-160
100-160
100-160
100-150
80-130
70-120
70-110
60-100
60-100
60-100
Well child
Sick child
Not playful
Not much interaction
Irritable
Unhappy
Cries more than usual, inconsolable
Sleepy
Difficult to waken
Floppy
Fever
Tachypnea
Tachycardia
Cardiopulmonary
Resuscitation
Infants
Children
Rate/min
Depth
Site
100
1/3 of AP chest diameter
Lower half of the sternum not
over the xiphoid (below
intermammary line)
2 fingers technique. OR
2 thumb-encircling hands
technique (preferred).
100
1/3 to 1/2 of AP chest diameter
Lower half of the sternum not
over the xiphoid
Technique
TABLE 2.2: Medications to maintain cardiac output and for post-resuscitation stabilization
Medication
Dose
Comment
Dobutamine
Dopamine
Epinephrine
Norepinephrine
Sodium nitroprusside
0.1-2 g/kg/min*
1-8 g/kg/min
Inotrope, vasodilator
Inotrope, chronotrope; renal and splanchnic vasodilator in low doses; pressor in
high dose
Inotrope, chronotrope, vasodilator in low
doses; pressor in higher doses
Inotrope, vasopressor
Vasodilator; prepare only in D5W
6 body weight (in kg) = mg of drug to add to 100 ml D5W then, an IV rate of 1 ml/h delivers 1 g/
kg/min of drug.
*0.6 body weight (in kg) = mg of drug to add to 100 ml D5W, then, an IV rate of 1 ml/h delivers 0.1
g/kg/min of drug.
IO = Intraosseous.
Sodium bicarbonate
Procainamide
Naloxone
Magnesium sulfate
Lidocaine
Glucose
Atropine
Adenosine
Amiodarone
Dose
Medication
Slowly
May repeat every 3-5 min
Monitor ECG
Rapid IV/IO bolus
Monitor ECG and BP
Be cautious when administering with
other drugs that prolong QT
Remarks
4
Clinical Protocol in Pediatrics
Shock
Coma
Score
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
Coma
Oculovestibular reflex
Supratentorial lesions
Infratentorial lesions
i. Preceding brainstem
dysfunction
ii. Sudden onset
iii. Cranial nerve palsies
iv. Early respiratory
disturbances
Anaphylaxis
Features
Cutaneous
Upper respiratory
Lower respiratory
Cardiovascular
General
Dose
10
Oxygen Administration
Simple mask
5
6
8
10
12
15
<40%
45-50%
35%
45-50%
60%
60%
60%
Nonrebreathing mask
55-60%
60-80%
80-90%
90%
90-100%
Content
Osmolality
Na = 150 mmol/L
Cl = 150 mmol/L
Na = 75 mmol/L
Cl = 75 mmol/L
Glucose = 50 g/L
Na = 37 mmol/L
Cl = 37 mmol/L
HCO3 = 1 mmol/ml
Na = 1 mmol/ml
Na = 145 mmol/L
K = 4.5 mmol/L
Na = 90 mmol/L
K = 20 mmol/L
Citrate = 30 mmol/L
Glucose = 110 mmol/L
300 mOsmol/kg
428 mOsmol/kg
290 mOsmol/kg
320 mOsmol/kg
Younger children
Older children
50 ml/kg
75 ml/kg
100 ml/kg
30 ml/kg
50-60 ml/kg
70-90 ml/kg
13
Isonatremia (Acute)
Isonatremia (Chronic)
Hyponatremia
Hypernatremia
100 mmol/L
70-80 mmol/L
120 mmol/L
40-60 mmol/L
Birth-10 kg
11-20 kg
21-30 kg
100/kg
1000 + 50 /kg above 10
1500 + 20 /kg above 20
Hypovolemic
hyponatremia
i. Renal loss
ii. Extrarenal loss
(Gastrointestinal,
sweat, third space)
Isotonic saline
Initial
management
Further
5% Dextrose with
management 0.45% saline
Euvolemic
hyponatremia
Hypervolemic
hyponatremia
i. Syndrome of
i. Renal loss
Inappropriate
Antidiuretic Hormone
ii. Water intoxication
ii. Edematous state
iii. Drugs
(Mineralocorticoids)
Water restriction
Salt and water restriction
Frusemide, hypertonic
saline
Hypertonic saline,
dialysis
Blood Component
Transfusion
Irradiated RBC
Washed RBC
Frozen RBC
Neocytes
2. Platelets
Random donor platelets (RDP)
Platelet pheresis
Leukocyte-poor platelets
Preparations
Prepared from potential donors, are transfused most often.
Promote oxygen delivery for patients with active bleeding or
severe anemia.
Prepared by a variety of techniques to remove more than 99%
of leukocytes. Reduce febrile reactions; Prevent HLA
alloimmunization and CMV infection in potential transplant
recipients or those requiring chronic platelet transfusions.
Reduces transfusion associated graft-versus-host disease
(TAGVHD).
Washing red blood cells in saline removes most plasma
proteins and some leukocytes and platelets. Substitute for
homologous RBC in patients sensitive to a plasma component;
Avoid transfusion of anti-A and anti-B antibodies when
O-negative blood is used in patients who are type A, B, or AB.
Not often used today.
RBCs frozen in liquid nitrogen with glycerol as a cryoprotective
agent, can be stored for up to 10 years. Preserve autologous
RBC; maintain store of rare blood types.
Prepared by differential centrifugation or cell separators and
have a longer circulating life span than standard red cells, but
they are rarely used. Increase efficacy of individual transfusion
for patients with transfusion-dependent anemia, thalassemia,
etc.
After screening and informed consent, may be substituted for
volunteer RBC at patient request. Reduces multiple donor
exposure in chronically transfused patients.
May be collected preoperatively, by perioperative blood
salvage, or by acute normovolemic hemodilution to decrease
homologous red blood cell use.
Obtained from whole blood.
Obtained by apheresis technology. Also known as single donor
platelet (SDP). It has advantages over RDP.
Various techniques to prepare are available. It can remove
>99% of leukocytes. It reduces febrile reactions and HLA
alloimmunization and CMV transmission.
Contd...
15
Contd...
Irradiated platelets
HLA matched platelets
Cryoprecipitate
4. Granulocytes
Leukapheresis
16
Therapeutic use
Albumin (heat-treated)
Plasma-derived factor VIII concentrate
Humate-P
Prothrombin complex concentrate
Bacteria
Spirochetes
Parasites
Prion
Hepatitis A, B, C
Parvovirus B 19
Cytomegalovirus
Epstein-Barr virus
HTLV 1 and 2
HIV
West Nile virus
Environmental
contaminants
Donor transmitted:
Yersinia, Salmonella,
Klebsiella
Serratia
Staphylococcus
Syphilis
Lyme disease
Malaria
Babesiosis
Chagas disease
Toxoplasmosis
Variant
CreutzfeldtJakob
disease
17
Febrile-nonhemolytic
transfusion reaction (FNHTR)
Transfusion-related acute
lung injury (TRALI)
Noncardiogenic pulmonary edema with fevers, chills, tachycardia, and diffuse pulmonary infiltrates shortly after transfusion,
due to leukocyte incompatibility. Resolves in 1-4 days; rarely
results in respiratory failure. Occurs in approximately 1:5000
transfusions.
Allergic reactions
Transfusion-associated
circulatory overload (TACO)
Dilutional effects
Hypocalcemia
Hyperkalemia
Hypothermia
Transfusion associated
Graft-versus-host disease
18
Contd...
Iron overload
Post-transfusion purpura
Miscellaneous
Transudate
i.
ii.
iii.
iv.
Exudate
i.
ii.
iii.
iv.
v.
vi.
<0.5
Pneumonia
Trauma
Tuberculosis
Rheumatoid arthritis
SLE
Malignancy
>0.5
<0.6
<2/3 upper limit of serum
LDH
>0.6
>2/3 upper limit of serum
LDH
Primary study
Prolonged Neonatal
Jaundice
10
Consider phototherapy
Institute phototherapy
Exchange transfusion if
phototherapy fails
12
15
17
15
18
20
20
25
25
24
25-28
49-72
72
TABLE 10.2: Indications for exchange transfusion and phototherapy in preterm babies
(Total serum bilirubin in mg/dL)
Birth weight (gram)
Upto 1000
1000-1250
1251-1500
1501-2000
2001-2500
>2500
Normal neonates
10-12
12-14
14-16
16-18
18-20
20-22
11
Neonatal Collapse
12
TABLE 12.1: Differences between croup, epiglottitis and foreign body aspiration
Parameters
Croup
Epiglottitis
Foreign body
Age
Onset
Prodromal features
Temperature
Stridor
6-18 months
Gradual, over 24-48 hours
Present
May be mildly elevated
High pitched loud
2-5 years
Sudden
Nil
High
Low pitched soft
Barking cough
Hoarse voice
General appearance
Present
Present
Noisy and playful
No cough
Voiceless
Anxious, sits still
>6 months
Sudden
Nil
Normal
Variable, depends on
location of foreign
body
Variable
Variable
Depends on degree
of obstruction
13
Croup
TABLE 13.1: Clinical Scoring System. By Westley CR, Cotton EK, Brooks JG
Level of consciousness
Cyanosis
Stridor
Air entry
Retraction
0
5
0
4
5
0
1
2
0
1
2
0
1
2
3
24
14
Acute Epiglottitis
Bronchiolitis
15
Moderate
Severe
Wheeze
Feeding
Entire expiration
Less than usual
Oxygen
Chest indrawing
No oxygen requirement
Nil/mild
Behavior
Normal
16
17
Cyanotic Spell
18
Heart Failure
30
19
TABLE 19.1: Normal respiratory and heart rate in children of different age groups
Age
RR / min
HR/ min
Birth
3 months
6 months
1 year
2 years
4 years
6 years
8 years
10 years
12 years
14 years
40-60
30-50
30-50
30-40
20-30
20
16
16
16
16
16
100-160
100-160
100-160
100-160
100-150
80-130
70-120
70-110
60-100
60-100
60-100
Supraventricular tachycardia
Usually HR >220/min
P waves if visible are usually negative in leads
II, III and AVF in SVT
No beat-to-beat variability of HR in SVT
Termination is abrupt
Clinical scenario usually points towards some
pre-existent or co-existent cardiac disorders.
32
33
34
20
Examination
Weight loss
Lack of energy
Fever
Change in bowel habit
Urinary symptoms
Intestinal symptoms
Vomiting: continuous,
bile stained, hematemesis
viii. Rectal bleeding
Various manifestations
Non-organic
Periodic, usually in day, good
in-between. Often periumbilical.
i. Migraine
ii. School and family problem
iii. Isolated vomiting, not bile stained
36
21
Upper Gastrointestinal
Bleeding
1 month to 1 year
1 year to 12 years
Adolescents
i. Gastritis
i. Esophageal varices
i. Esophageal varices
ii. Gastritis
ii. Gastritis
iii. Esophagitis
iv. Mallory-Weiss
syndrome
v. Vascular
malformation
vi. GIT duplication
v. Mallory-Weiss
syndrome
vi. Peptic ulcer
v. Mallory-Weiss
syndrome
vi. Peptic ulcer
vii. Foreign body
38
39
40
22
Asterixis
EEG changes
Clinical manifestations
Stage 1 Prodrome
Slight
Minimal
Stage 2 Impending
coma
Easily elicited
Generalized slowing
of rhythm
Stage 3 Stupor
Present if patient
is cooperative
Grossly abnormal
slowing
Stage 4 Coma
Usually absent
Appearance of delta
waves, decreased
amplitudes
23
Signs
Diagnosis
Dehydration, shock
Variable, depending on
individual condition
Gastroenteritis, hypovolemia
Petechiae, bleeding
Sepsis, DIC
Suspect HUS, confirm with
laboratory results
Pyelonephritis
Acute glomerulonephritis
Drug induced ARF
Obstructive uropathy
Flank tenderness
Hypertension/edema
Suprapubic mass
Renal
History/clinical features
Dehydration, hypovolemia
Yes
Renal indices
Specific gravity
Urinary sodium
Urine/plasma osmolality
FENa
Diuretics and fluid challenge
>1020
<20 mEq/L.
>1:3
<1(< 2 in newborn)
Positive response
normal
>20 mEq/L
<1:3
>1(>2 in newborn)
No response
Anemia
Hypertension
Metabolic acidosis
vi.
iv.
v.
i.
ii.
iii.
Pulmonary edema
Hyperkalemia (K>5.5 mEq/L)
Treatment
Complication
43
44
45
Hypertensive Crisis
24
Cause
Newborn
Adolescence
Class
Dose
Route
Comments
Esmolol
blocker
100-500 g/kg/min
IV infusion
Hydralazine
Vasodilator
0.2-0.6 g/kg/min
IV/IM
Labetalol
Nicardipine
Sodium
Nitroprusside
IV bolus or
infusion
IV infusion
IV infusion
Hypertensive Crisis
ii. Vascular:
Miscellaneous:
Endocrine:
Cardiovascular:
Drugs:
Henoch-Schnlein purpura
Postinfectious glomerulonephritis
Systemic lupus nephritis
Rapidly progressive glomerulonephritis
Hemolytic-uremic syndrome
Renal artery stenosis and thrombosis
Renal vein thrombosis
Sickle cell nephropathy
Polycystic kidney disease
Tuberous sclerosis
Hydronephrosis
Renal hypoplasia
Obstructive uropathy
Iatrogenic fluid overload
Renal failure with fluid overload
Reflux nephropathy
Renal tumors
Pheochromocytoma
Congenital adrenal hyperplasia
Aortic thrombosis
Aortic coarctation
Aortic insufficiency
Subacute bacterial endocarditis
Corticosteroids
NSAIDs
Oral contraceptive pills
Theophylline
Phenylephrine
47
48
Hypertensive Crisis
49
50
25
Hematuria
26
Status Epilepticus
Stage I
Lorazepam0.05 to 0.1 mg/kg IV (maximum 4 mg) or
Diazepam0.3 mg/kg IV (maximum 10 mg) undiluted over 2 minutes.
If IV access could not be established
Diazepam rectal 0.5 mg/kg or
MidazolamIM 0.2 mg/kg.
Stage II
Repeat lorazepam0.05 to 0.1 mg/kg IV (maximum 4 mg) or
Diazepam0.3 mg/kg IV (maximum 10 mg) undiluted over 2 minutes.
Then start
Phenytoin15 to 20 mg/kg (maximum dose 1000 mg) IV infusion at the rate 1 mg/kg/min
under ECG monitor. Prepare infusion as 10 mg phenyton/ml NS or
Fosphenytoin30 mg/kg IV infusion at the rate 3 mg/kg/min.
Consider pyridoxine100 mg IV for children <2 years of age.
Start 20 percent mannitol5 ml/kg over 20 minutes.
If still convulsing 10 minutes after starting phenyton a 3rd dose of diazepam may be given.
Status Epilepticus
53
Stage III
PhenobarbitoneLoading dose 15 to 20 mg/kg IV, slowly over 10 minutes.
Be prepared for ventilation and if there is response continue maintenance
Phenobarbitone5 mg/kg/day every 12 hours.
If no response in 5 to 10 minutes after end of infusion or seizure already more than 60 minutes
or unstable vital signs.
Stage IV (ICU)
Intubation and ventilation muscle relaxant (use short acting muscle relaxant in repeated doses
to monitor seizure when EEG monitoring is not available).
Midazolam0.2 mg/kg IV bolus.
Then infusion 1 to 2 mcg/kg/minute titrated up to10 mcg/kg/min
(During infusion maintain phenytoin and phenobarbitone at high therapeutic level) or propofol
1 to 2 mg/kg followed by 2 to 10 mg/kg/hour. If seizure is not controlled in 1 to 2 hours induce
barbiturate coma.
Thiopentone2 to 8 mg/kg loading then reduce infusion to 1 to 10 mg/kg/hour when needed,
titrating for best control.
Monitor for BP, hypoglycemia, electrolytes imbalance, hypocalcemia, acidosis consumptive
coagulopathy (PT, APTT) and hyperpyrexia.
Restrict fluid to 60 percent maintenance (Unless low BP) and continue treatment for brain
edema with mannitol every 6 hours dexamethasone (With IV ranitidine).
After stabilization consider CT scan brain and work-up for possible causes.
Treat for CNS infection if indicated (LP after brain CT scan).
27
Rapid Onset
Limb Weakness
Poliomyelitis
Less than 4 days, max. 7 days
Present
Proximal, asymmetrical
Diminished
Decreased or absent
Myalgia, back ache
Only when bulbar or bulbospinal
Only when bulbar or bulbospinal
Transient retention
Severe asymmetric atrophy
High
Normal or slight increase
Normal then slight decrease
Abnormal
Progression of paralysis
Fever at onset
Flaccidity
Muscle tone
DTRs
Sensation
Cranial nerve
Decreased respiration
Bladder dysfunction
Sequele
CSF: WBC
CSF: Protein
NCV (3 wks)
EMG (3 wks)
GBS
Transverse myelitis
Traumatic neuritis
55
Perinatal
14.
15.
16.
13.
12.
9.
10.
11.
1.
2.
3.
4.
5.
6.
7.
8.
Starvation
Idiopathic ketotic hypoglycemia
Hypopituatrism
Hypoadrenalism
Hypothyroidism
Growth hormone deficiency
Inborn error of metabolism
Amino acid metabolic abnormality
Islet cell adenoma
Islet cell hyperplasia
Functional beta cell secretory
defect
Factitious insulin use or sulfonylurea use
Beckwith-Wiedemann syndrome
Infection
Hypothermia
Congenital heart disease
Infancy
1. Idiopathic ketotic hypoglycemia
2. Drug-induced (salicylate, alcohol)
3. Islet cell adenoma
4. Islet cell hyperplasia
5. Factitious insulin or sulfonylurea
use
6. Beckwith-Wiedemann syndrome
7. Infection
8. Hypothermia
9. Large non-beta cell tumors
10. Fulminant hepatic disease
Childhood
28
Hypoglycemia in Neonates
and Children
57
58
29
HypothalamicPituitary Disease
Biosynthetic Defect
(CAH 21-O Hase)
Deficient hormone(s)
Cortisol
Aldosterone
Cortisol Aldosterone
(Salt wasting variant)
Hyperpigmentation
Serum Na+
Yes
Low (salt wasting)
Serum K+
Serum ACTH
Cortisol response
to IV ACTH
17-OH progesterone
response to IV ACTH
High
High
None
ACTH/CRF Cortisol
(Aldosterone pathway
intact)
No
Mildly low when
patient well (unable
to excrete free water
load)
Normal
Low
Increase
None
Increase
Exaggerated
Yes
Low if salt waster
Animal Bites
30
Type of contact
Type of
exposure
Recommended postexposure
prophylaxis
None
II
III
Minor
Severe
Note: After carefully assessing the category of exposure, the treating doctor should evaluate the course of
action to be taken, based on the following general considerations. He should also keep in the mind that with
the presently available safe cell culture rabies vaccines (CCRV), it is always safe to offer treatment rather
than withhold in doubtful situations.
31
Snake Bite
32
Near Drowning
33
Various Poisonings
64
Ferrous sulfate
20
12
33
35
Elemental iron
mg/kg of body weight
Serum iron at
4 hours (gm/dL)
Serum iron at 4
hours (mol/L)
Mild
Moderate
Severe
Lethal
<30
>30
>60
>150
110-300
300-500
500
1000
20-55
55-90
>90
>180
Clinical features
I.
0.5-6 hours
II.
6-24 hours
III.
12-48 hours
IV.
2-4 days
V.
2-8 weeks
Level of severity
Mild
Moderate
Severe
Various Poisonings
65
34
67
24.8%
Manganese dioxide
Zinc/Air
16%
Manganese dioxide
AlkalineManganese
LithiumManganese
0.3%
5%
3%
Mercury
Silver
Manganese
dioxide
Main constituent
Types
10%
12%
7%
8%
Potassium
hydroxide
7%
14%
13%
Zinc powder
amalgum
1.8%
3%
1.5%
Graphite
0.5%
0.5%
0.15%
Zinc
oxide
Propylene
carbonate 6%,
Lithium
perchlorate 1%,
Lithium metal
anode 2%,
Ethylene
glycoldimethyl
ether 4.3%
Carbon black 2%,
Mercury metal 1%
Sodium aluminate
0.05%
Cement 1.5%
Others
35
Button Battery Ingestion
69
Usually suggests
Croup
Anxiety
Many potential medical and surgical causes
Idiopathic abdominal pain of later childhood
Gastroenteritis, other medical or surgical conditions
Wide variety of medical problems
Epilepsy
Gynecological cause
Systemic disease
Acute neurological problem
Drug overdose, acute neurological condition
Hypocalcemia
Epilepsy variant
Glue ear, congenital deafness
Organic cause
Major systemic illness
Symptom / sign
Acute stridor
Hyperventilation
Chronic pain
Seizures
Amenorrhea
Diffuse muscle pain
Limb paralysis
Confusional state
Carpopedal spasm
Complex partial seizure
Deafness
Mutism
Inanition, inability to walk, speak
May be an indication of
TABLE 36.1: Symptoms and signs which may indicate both medical and psychiatric conditions
36
Psychiatric Assessment
for Nonpsychiatrists
37
Head Trauma
38
39
40
Stability
Very unstable
Unstable
Unstable
Unstable
Unstable
Stable
Very stable
Very unstable
Unstable
Unstable (in extension)
Unstable
Stable
Very unstable
Stable
SCIWORA
75
41
Ophthalmological Issues
Otolaryngological Issues
42
Causes
Otitis externa
Foreign body
Trauma
Perichondritis infected preauricular cyst or sinus
Acute otitis media
Middle ear effusion
Barotrauma
Mastoiditis
Via trigeminal nerve:
i. Dental
ii. Temporomandibular joint
iii. Jaw
iv. Oral cavity
Via facial nerve:
i. Herpes zoster
ii. Bells palsy
Via glossopharyngeal nerve:
i. Tonsil
ii. Oropharynx
iii. Nasopharynx
Via vagus nerve:
i. Laryngopharynx
ii. Esophagus
iii. Thyroid
Via cervical nerves:
i. Lymphnodes
ii. Cervical spine
iii. Neuralgia
Others:
i. Migraine
ii. Sinuses
iii. Salivary gland
iv. CNS
Referred
78
43
Conditions
Viral
Bacterial
Inflammatory diseases
Malignancy
Miscellaneous
Maculopapular
Petechiae or Purpura
Vesico-bullous
Staphylococcal SSS
Toxic shock syndrome
Anaphylaxis
TEN
Scarlet fever
Viral exanthem
(measles, roseola,
rubella)
Urticaria
Lyme disease
Pityriasis
Drug reaction
Erythema multiforme
Stevens-Johnson
syndrome
Meningococcemia
Rocky Mountain
spotted fever
Eczema, Psoriasis
Meningococcemia
ALL
HSP
TTP
ITP
Vasculitis
Varicella Zoster
HSV
DIC
Pemphigus vulgaris
Bullous pemphigus
Necrotizing fascitis
Contact dermatitis
HFM disease
Stevens-Johnson
syndrome
44
Dose
0.5 mg/kg/dose every 8 hourly
0.35 mg/kg/day
1-2 mg/kg/day
0.2 mg/kg/day
0.25 mg/kg/day
30 mg 12 hourly (6-12 years)
5 mg/day (used above 2 years)
2.5 mg (used above 6 years)
45
Unwell
Appearance
Sick looking (lethargy, reduced activity) Absent eye contact, does not
recognize parents, no activity
Whimpering
Weak cry, high pitched cry
Slow response, unwilling
Too weak to respond
Drowsy
Frequently falls sleep, difficult
to wake
Slightly dry mouth
Dry mouth, sunken fontanelle,
doughy skin
Peripheral cyanosis or pallor
Mottled pale face or ashen
Briefly smiles and responds
Not smiling, anxious face,
expressionless
Quality of cry
Response to cuddling
Alertness
Hydration
Color
Sociability/stimulation
Very unwell
82
83
Severe and
Complicated Malaria
46
Frequencya
Prognostic value
Clinical manifestation
+
Prostration
+++
Impaired consciousness
+++
Respiratory distress (acidotic breathing)
+
Multiple convulsions
+++
Circulatory collapse
+++
Pulmonary edema (radiological)
+++
Abnormal bleeding
++
Jaundice
+
Hemoglobinuria
Laboratory findings
+
Severe anemia
+++
Hypoglycemia
+++
Acidosis
+++
Hyperlactatemia
+/Hyperparasitemia
++
Renal impairment
a
+++
+++
+++
+++
+
+/+/+
+/+++
+++
+++
+++
++
+
5-15 kg
>15-25 kg
>25-35 kg
above 35 kg
20 mg + 120 mg
40 mg + 240 mg
60 mg + 360 mg
80 mg + 480 mg
Dengue
47
IgG
Interpretation
Negative
Negative
Negative
Positive
Positive
Positive
Negative
Positive (Low titer)
Positive (High titer)
Negative
Positive (Low titer)
Positive (High titer)
Early sample
Postdengue infection
Secondary dengue infection
Primary dengue infection
Current or recent dengue infection
Secondary dengue infection
86
Community Acquired
Pneumonia
48
First line
Second line
3-5 months
>5 months
Amoxicillin
Amoxicillin
Co-amoxyclav
Macrolides / co-amoxyclav
First line
Second line
<3 months
3 months - 5 years
Cefotaxime/ceftriaxone
Co-amoxyclav/ampicillin
>5 years
Ampicillin/co-amoxyclav/macrolide
Suspected staphylococcus
Cefuroxime/co-amoxyclav/3rd
generation cephalosporin
Add aminoglycoside
Co-amoxyclav/cefotaxim/
ceftriaxone
Cefotaxime/ceftriaxone/
macrolide
Ceftriaxone/cefotaxime/
vancomycin/linezolid
Normal child
20-45 mg/dL
Protein
84 45 mg/dL
46 10 mg/dL
>50
Glucose
viral
10-500
TB
Normal
Partially treated
Low or normal
Polymorphs or
lymphocytes
5-10000
Very high,
High,
100-3000 mg/dL 100-500 mg/dL
Low
Increased
rarely >1000
Low, <50%
of serum
Polymorphs
300-2000
<5
Predominant >75%
cells
lymphocytes
WBC
49
Acute Meningitis
50
Dosage
Trimethoprim-sulfamethoxazole
Amoxicillin/co-amoxyclav
Cephalexin
Cefixime
Cefuroxime axetil
Cefpodoxime
Daily Dosage
Ceftriaxone
Cefotaxime
Ceftazidime
Gentamicim
Amikacin
Ampicillin
Indication
Rationale
Dosage
2 mg TMP once daily
1 mg/kg dose once daily
25 mg/kg dose once daily
Trimethoprim-sulfamethoxazole
Nitrofurantoin
Cephalexin
Prophylactic antibiotics
Radionuclide cystogram
DMSA Scan
Ultrasound abdomen
MCUG
Investigation
90
Clinical Protocol in Pediatrics