Paeds am ks teach surgical revision weekend
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Paeds am ks teach surgical revision weekend Paeds am ks teach surgical revision weekend Presentation Transcript

  • + 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.p df  Punnett Square: http://upload.wikimedia.org/wikipedia/commons/2/22/Punnett_Squar e.svg  Ortolani/Barlow’s Manoeuvre http://www.cssd.us/body.cfm?id+512