Paeds am ks teach surgical revision weekend

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Paediatrics for the AMK

By Dr Eva Wooding

+ Learning Objectives

Revise key Indicative Presentations for the AMK including…

Paediatric emergencies (“what would you do first?”)

Common inherited conditions

Community Paediatrics (normal development,

vaccinations)

Common childhood infections and their management

Fractures and common injuries

+ Q: Febrile Child

A mother from Totnes brings her 22 month old daughter to ED. She has been off colour for 5 days and visibly unwell for 48 hours with a coryzal illness, pyrexia and lethargy. She had Calpol 2 hours ago. O/E: HR 165, RR 35, Sats 97% on air, BP 90/60, Cap Refill 3 secs, Temp 37.6oC. A maculopapular rash visible on the face, mild cervical lymphadenopathy and conjunctivitis. The child has not had any regular vaccinations. She is looked after at home, but attended a playgroup until 2 weeks ago.

What’s your primary diagnosis?

A: Bacterial Meningitis

B: Kawasaki Disease

C: Fifth Disease

D: Chickenpox

E: Rubella

+ Q: Febrile Child

A mother from Totnes brings her 22 month old daughter to ED. She has been off colour for 5 days and visibly unwell for 48 hours with a coryzal illness, pyrexia and lethargy. She had Calpol 2 hours ago. O/E: HR 165, RR 35, Sats 97% on air, BP 90/60, Cap Refill 3 secs, Temp 37.6oC. A maculopapular rash visible on the face, mild cervical lymphadenopathy and conjunctivitis. The child has not had any regular vaccinations. She is looked after at home, but attended a playgroup until 2 weeks ago.

What’s your primary diagnosis?

A: Bacterial Meningitis

B: Kawasaki Disease

C: Fifth Disease

D: Chickenpox

E: Rubella

+ Common Childhood Infections

Meningitis

Rash associated with bacterial septicaemia (non-blanching, maculopapular). Expect higher fever

Immediate Management?

Rubella

Respiratory spread, 14-21 day incubation.

Fever, then spreading maculopapular rash

(face to trunk) which fades in 3-5 days.

!! Pregnancy !!

Fifth Disease

Aka ‘Slapped Cheek’ caused by Parvovirus. Painless rash on one/both cheeks. Mild fever, usually self-limiting. Peak incidence April/May

Chickenpox

Respiratory spread. 10-21 day incubation. Clusters of vesicles over head/neck/trunk. Intensely itchy. Papule Vesicle Pustule Crust + Scratch marks

Kawasaki’s (vasculitis)

Fever >5 days + Strawberry tongue, peeling skin (desquamation) ,

cervical lymphadenopathy, bilateral conjunctivitis. Complications:

myocardial ischaemia and sudden death

+ Rashes of Childhood Diseases

+ Normal Reference Ranges in Children

They are different!

+ Q: Abdominal Pain

A 2 year old boy is brought to his GP with intermittent screaming

and pain, followed by periods where he is quiet and withdrawn.

He has had one loose, jelly-like stool passed today. O/E there is a

mass palpable in his abdomen.

A: Meckel’s Diverticulum

B: Gastroschisis

C: Intussusception

D: Sigmoid volvulus

E: Appendicitis

+ Q: Abdominal Pain

A 2 year old boy is brought to his GP with intermittent screaming

and pain, followed by periods where he is quiet and withdrawn.

He has had one loose, jelly-like stool passed today. O/E there is a

mass palpable in his abdomen.

A: Meckel’s Diverticulum

B: Gastroschisis

C: Intussusception

D: Sigmoid volvulus

E: Appendicitis

+ Paediatric Acute Abdomen

Intussusception

Cause of 25% of acute abdomen

in children <5. Male: female 3:2.

Usually sudden onset, colicky in

nature. ‘Sausagey mass’,

‘redcurrant jelly stool’

Meckel’s Diverticulum

Embryological remnant of vitellointestinal tract. Presents with intermittent, painless blood PR. Dx via Technetium scan to find ectopic gastric mucosa

Gastroschisis

Where abdomen is not covered by peritoneum.

This is found prenatally or postnatally and repaired surgically

Appendicitis

Rarer cause of acute abdomen for age group (usually 10-20y/o).

Migratory pain, not colicky. O/E usually no mass to palpate

+ Q: Respiratory Distress

A 6 year old African-Caribbean girl comes to ED with her

father. She appears lethargic and is sat quietly, but clearly

struggling to breathe. She has been unwell for around 6

hours and is sat forward dribbling. What is the diagnosis?

A: Epiglottitis

B: Croup

C: Bronchiolitis

D: Foreign body inhalation

E: Sickle cell crisis

+ Q: Respiratory Distress

A 6 year old African-Caribbean girl comes to ED with her

father. She appears lethargic and is sat quietly, but clearly

struggling to breathe. She has been unwell for around 6

hours and is sat forward dribbling. What is the diagnosis?

A: Epiglottitis

B: Croup

C: Bronchiolitis

D: Foreign body inhalation

E: Sickle cell crisis

+ So you think it’s Epiglottitis…

What do you do next?

A: Start broad spectrum antibiotics

B: Examine the throat for site of obstruction

C: Start high flow Oxygen

D: Call the anaesthetist

E: Order a Chest X-ray

+ So you think it’s Epiglottitis…

What do you do first?

A: Start broad spectrum antibiotics

B: Examine the throat for site of obstruction

C: Start high flow Oxygen

D: Call the anaesthetist

E: Order a Chest X-ray

+ Respiratory Tract Infections

Epiglottitis

Causes severe life-threatening stridor quickly due to H. Influenzae infection. If suspected, don’t delay urgent GA and upper airway endoscopy needed

Croup

Usually mild, viral illness. Also causes stridor and a barking cough (like a sealion). May have fever and develops more slowly.

Usually affects children 6m to 5yrs

Bronchiolitis

Viral RTI affecting children under 2 years (peak 3-6m). Seasonal illness (winter). Usually caused by Respiratory Syncytial Virus (RSV). Treat with fluids, O2

Foreign Body

Sudden onset of SOB ± history of

aspiration from observer.

Unilateral signs

(wheeze/reduced air entry). RHS

more common

+ Q: Childhood Injuries

A 10 month old boy presents to ED crying and clutching his right arm. He cries out when you attempt examination. His mother describes an accurate method of injury (fall from side of cot onto tiled floor) and brought the child immediately to ED. X-ray demonstrates

What part of the history will be most helpful for

informing on going management?

A: Family history

B: Past Medical history

C: Dietary history

D: Developmental history

E: Drug history

+ Q: Childhood Injuries

A 10 month old boy presents to ED crying and clutching his right

arm. He cries out when you attempt examination. His mother

describes method of injury (fall from side of cot onto tiled floor)

and brought the child immediately to ED. X-ray demonstrates

What part of the history will be most helpful for

informing on going management?

A: Family history

B: Past Medical history

C: Dietary history

D: Developmental history

E: Drug history

+

+ Highly Suspicious Injuries

Long bone fractures in non-ambulatory children

Any fracture under 6 months

Spiral fractures

Rib fractures in infant (Shaken baby) esp. Posterior

Depressed skull fractures

NB. Safeguarding!

+ Q: Vaccinations

A 3 1/2 year old girl from Exeter attends her practice nurse with her pregnant mother for her MMR vaccine. She is usually fit and well except for Asthma. She recently had a RTI but is now afebrile following a 1 week course of steroids. She is allergic to eggs. Her brother has previously had a reaction to the MMR vaccine.

What is the contraindication to having her MMR today?

A: Egg allergy

B: Recent steroids

C: Family History of vaccine reaction

D: Recent infection

E: Mother’s pregnancy

+ Q: Vaccinations

A 3 1/2 year old girl from Exeter attends her practice nurse with her pregnant mother for her MMR vaccine. She is usually fit and well except for Asthma. She recently had a RTI but is now afebrile following a 1 week course of high dose steroids. She is allergic to eggs. Her brother has previously had a reaction to the MMR vaccine.

What is the contraindication to having her MMR today?

A: Egg allergy

B: Recent steroids

C: Family History of vaccine reaction

D: Recent infection

E: Mother’s pregnancy

+ Childhood Vaccinations

Live Vaccines

• MMR

• BCG

Inactivated/Polysaccharide/

Toxoid Vaccines

• DTaP/IPV/Hib (Pediacel)

• Tetanus

• Influenza

• Pneumococcus

True Contraindications to

Vaccination

• Egg anaphylaxis (influenza,

yellow fever)

• Prednisolone 2/mg/kg/day

for >6 days

• Impaired immunity

• Chemo/RadioRx in last 6 wks

• Bone marrow transplant in

last 6 months

• Immunosuppression with

cytotoxic drugs

+ Q: Mobility Problems

A 4 year old boy attends Paediatric Outpatient Clinic with

difficulty walking, and trips. Developmentally, he sat up by 9

months and was walking by 20 months. His mother has noticed a

limp. O/E he has unsteady gait and poor balance.

The doctor diagnoses Muscular Dystrophy. How is this inherited?

A: Autosomal Dominant

B: X-linked Recessive

C: Autosomal Recessive

D: Polygenic Inheritance

E: X-linked Dominant

+ Q7: Mobility Problems

A 4 year old boy attends Paediatric Outpatient Clinic with

difficulty walking, and trips. Developmentally, he sat up by 9

months and was walking by 20 months. His mother has noticed a

limp. O/E he has unsteady gait and poor balance.

The doctor diagnoses Muscular Dystrophy. How is this inherited?

A: Autosomal Dominant

B: X-linked Recessive

C: Autosomal Recessive

D: Polygenic Inheritance

E: X-linked Dominant

+ Heritance Patterns

Autosomal Dominant

Familial hypercholesterolaemia – 1

in 500

Polycystic kidney disease – 1 in 1250

Marfan Syndrome – 1 in 4000

Huntington Disease – 1 in 15 000

X-Linked (recessive)

Red-Green colour-blindness

Duchenne’s and Becker’s Muscular

Dystrophies

Fragile X syndrome

Haemophilia A and B

Autosomal Recessive

Sickle cell disease – 1 in 625 (Black

African-Caribbeans)

Cystic fibrosis – 1 in 2500

(Caucasians)

Tay-Sacs disease – 1 in 3000

(Ashkenazi Jews)

Others

X-linked (Dominant): Vitamin D resistance Rickett’s

Mitochondrial (passed by mother)

Polyfactorial (congenital or acquired) e.g. Diabetes, Epilepsy…

+ Punnett Square

Which/who is the…?

Heterozygote

Homozygote

Dominant allele?

Affected child?

Unaffected?

What type of heritance is this?

+

Bonus Question What are the names of the two hip tests we carry out to look for

congenital hip disorders in neonates?

+ Congenital Hip Malformations

Ortolani’s

Flex hip to 90o then

move hips OUT

Tests for posterior

disclotion

Barlow’s

Move hips inwards

Tests for posterolateral dislocation

+ Q: Managing Epilepsy

A 7 year old child with known Epilepsy is having a seizure in

a GP’s waiting room. You are called to assess them. This

seizure has continued for 5 minutes. What should you do first?

A: Secure the airway

B: Call an ambulance

C: Remove objects from around the child e.g. chairs

D: Give Midazolam

E: Give Diazepam

+ Q: Managing Epilepsy

A 7 year old child with known Epilepsy is having a seizure in

a GP’s waiting room. You are called to assess them. This

seizure has continued for 5 minutes. What should you do first?

A: Secure the airway

B: Call an ambulance

C: Remove objects from around the child e.g. chairs

D: Give Midazolam

E: Give Diazepam

+ Seizures and their management

Emergency Management for seizures lasting >5 mins:

Call 999

Give buccal Midazolam in the community, IV Lorazepam if IV

access available (or PR Diazepam)

Status Epilepticus = seizure (or cluster of seizures) lasting >10

mins.

Treated with Benzodiazepines Phenobarbitol Phenytoin

+ Summary and Top Tips

If it’s obvious, go for it; they’re probably not trying to trick you!

Read the vignettes carefully looking for key words. Bring a

highlighter if that helps

Write things out if that works for you, especially for genetics

questions

If the question asks what you’d do FIRST… it’s probably “high flow

oxygen”

Don’t get too bogged down with details, remember the big stuff

and the common stuff and you’ll be fine!

+ Some Key Words/Phrases

Strawberry tongue and

‘desquamation’ of palms =

Kawasaki’s

Redcurrant jelly

stool/sausagey mass =

Intussusception

Sick child sat forward and

drooling = epiglottitis

Barking cough = Croup

Spiral fracture = Non-accidental

injury

+ Learning Objectives

Revise key Indicative Presentations for the AMK including…

Paediatric emergencies (“what would you do first?”)

Common inherited conditions

Community Paediatrics (normal development,

vaccinations)

Common childhood infections and their management

Fractures and common injuries

+

Thank you! Any questions?

evawooding@nhs.net

+ Further Reading and References

Etheridge, L (ed.) Oxford Assess and Progress: Clinical Specialties 2010 OUP: Oxford.

Core Clinical Cases in Paediatrics 2nd ed. Ewer A, Gupta R, Barrett T, Gupta J. 2011 Hodder Arnold: London.

Orekunrin O, Chaplin H. Revision Questions for Paediatrics. 2010 Radcliffe: Oxford.

Patient UK, 2013. Accessed online: http://www.patient.co.uk/doctor/Paediatric-Examination.htm (accessed 08/10/13).

University of Texas, 2013. Accessed online: http://www.utmb.edu/pedi_ed/CORE/Abuse/page_08.htm (accessed 08/10/13).

Almost A Doctor: Mind Maps, 2013. Accessed online: http://almostadoctor.co.uk/sites/all/MindMaps/409.pdf (accessed 08/10/13)

+ Picture References

Pictures are copyright and royalty free unless referenced

Chickenpox http://www.theintellectualdevotional.com

Kawasaki’s disease:http://en.wikipedia.org/wiki/File:Kawasaki_symptoms_B.jpg

Meningococcal septicaemia: http://www.wales.nhs.uk/sites3/page.cfm?orgId=457&pid=32261

Spiral Fracture: http://www.utmb.edu/pedi_ed/CORE/Abuse/page_08.htm

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/204061/DoH_Imm_schedule_poster_A4_2013_07_accessible.pdf

Punnett Square: http://upload.wikimedia.org/wikipedia/commons/2/22/Punnett_Square.svg

Ortolani/Barlow’s Manoeuvre http://www.cssd.us/body.cfm?id+512