Medicine Notes Paediatrics Notes
Paediatric notes based upon current NICE guidance, The Illustrated Textbook of Paediatrics by Lissauer and Clayden in conjunction with the Oxford Handbook of Paediatrics...
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Infection and Immunity
Maybe look at the pictures of various rashes
The Febrile Child See NICE guidance
Most have brief, self limiting viral infections or mild localised infections (otitis media, tonsillitis)
Clinical Features
Risk factors for infection
Illness of family members
Illness in the community
Unimmunised
Recent travel abroad (malaria, typhoid)
Contact with animals
Immunodeficiency
Sickle cell disease, splenectomy, nephrotic syndrome increased susceptibility to encapsulated organisms (Strep. pneumoniae, Hib, salmonella)
How if fever identified?
In hospital it is measure at:
<4 weeks old – electic thermometer in the axilla
4 weeks – 5 years electric or chemical dot thermometer in the axilla or infrared tympanic thermometer
Axillary temperature is 0.5oC less than body temperature
How old is the child?
Febrile infants <3 months present with non specific clinical features (SEE neonatal infection notes)
Often have bacterial infection
Viral infections are uncommon due to massive maternal immunity
Should have vital signs measured and recorded
Temp
HR
RR
If no source is obvious - require urgent investigation with septic screen and IV antibiotics
FBC, Blood culture
WCC
Acute phase reactant (CRP)
Urine
Consider (if red flags)
CXR,
Lumbar puncture,
Stool culture,
Serum electrolytes
Blood gas
Meningococcal and pneumococcal PCR on blood/CSF, PCR for viruses in CSF (HSV, enterovirus)
Start parenteral antibiotics if:
<1 month old
1-3 months and unwell
1-3 months with altered WCC
How ill is the child?
Measure
Temp
Fever >38 if <3 months
Fever >39 if 3-6 months
HR
If raised can indicate SHOCK
RR
Cap refill
Assess for signs of dehydration
Prolonged cap refill
Abnormal skin turgor
Abnormal resp rate
Weak pulse
Is there a focus for infection?
When there is no apparent cause of infection the differential should include the following:
Diagnosis | Symptoms and Signs |
---|---|
Meningococcal Disease | Non blanching rash with one or more of:
|
Meningitis | Neck stiffness Bulging fontanelle Decreased consciousness Convulsive status epilepticus (Classic signs are often absent in infants) |
HSV Encephalitis | Focal neurology Focal seizures Decreased consciousness |
Pneumonia | Tachypnoea
Crackles Nasal flaring Chest indrawing Cyanosis Oxygen sats <95% |
UTI | Vomiting Poor feeding Lethargy Irritability Abdominal pain Frequency / dysuria Offensive urine / haematuria |
Septic Arthritis / Osteomyelitis | Swelling of a limb or joint Not using an extremity Non-weight bearing |
Kawasaki Disease | Fever lasting longer than 5 days plus four of:
|
Traffic Light System to Identify Serious Illness
Green | Amber | Red | |
---|---|---|---|
Colour | Normal | Pallor | Pale, mottled, ashen or blue |
Activity | Responds normally Content, smiles Stays awake Awakens quickly when roused Strong normal cry | Not responding normally Decreased activity Prolonged stimulation required to awaken | Unresponsive Barely rousable Weak, high pitched or continuous cry |
Breathing | Normal | Nasal flaring Tachypnoea Desaturation (<95%) in air Chest crackles | Grunting Severe distress |
Hydration | Normal | Dry mucous membranes Poor feeding Reduced urine output Capillary refill >3s | Reduced skin turgor |
Other | Generally normal No fever | Fever >5 days Swelling of limb/joint New lump >2cm | Non blanching rash Fever at time of exam Bulging fontanelle Neck stiffness Seizures Focal neurology Bile stained vomit |
Management
Children with only green features and no definite diagnosis can be managed at home
Perform UTI, assess for symptoms and signs of pneumonia
Do not perform routine blood tests or XR
Amber features and no diagnosis
Urine test, FBC, Blood culture, CRP routine
Perform CXR IF fever >39 and WCC raised
Consider lumber puncture if <1 year old
Any Red features and no diagnosis
Blood culture, FBC, urine test, CRP
Lumbar puncture, CXR, electrolytes and blood gas as clinically deemed necessary
Parenteral antibiotics are given immediately to seriously unwell children
Third generation cephalosporin (cefotazime, ceftriaxone) if >3 months old
In infants;
Cefotaxime in septicaemia or meningitis
Ampicillin in listeria / Gp B strep
Aciclovir in HSV encephalitis
Anti-pyretics paracetemol or ibuprofen
Do NOT use damp sponge
Do NOT over- or underdress the child
Septicaemia
Bacteria may cause a focal infection or proliferate in the blood stream leading to septicaemia
In septicaemia the host response involves release of cytokines and activation of endothelial cells leading to septic shock
Commonest cause is meningococcal infection (+/- meningitis)
Incidence has reduced due to immunisation
Pneumococcus is the commonest organism causing bacteraemia (not typically septic shock)
In neonates are group B strep or gram negative organisms
Clinical spectrum produced by 4 elements:
Capillary leak
From presentation until day 2-4 vascular permeability massively increases
Protein enters intravascular space and urine causing severe hypovolaemia
Initial vasoconstriction to compensate but eventually decreased venous return and decreased cardiac output
Coagulopathy
Severe bleed tendency in meningococcaemia
Presents with severe thrombosis in microvasculature of the skin, often in a glove and stocking distribution, sometimes requiring amputation
Metabolic derangement
Profound acidosis occurs with severe metabolic abnormalities including hypokalaemia, hypocalcaemia, hypomagnesaemia and hypophosphataemia
Myocardial failure
Function remains impaired even after t...
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Paediatric notes based upon current NICE guidance, The Illustrated Textbook of Paediatrics by Lissauer and Clayden in conjunction with the Oxford Handbook of Paediatrics...
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