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Cardiology

Ductal Dependent Lesions

• Present 1^st week to 1^st month
• Normal duct seals by 3 weeks
• If dependent on shunt for pulmonary flow  cyanosis
• If dependent on shunt for systemic flow cold shock (may be worse w/ fluids)
• Prostaglandin E₁
  • 1 mg/kg/min
  • Side effects include apnea, bradycardia, hypotension, seizure
    • Consider intubating prior to administration
  • IVF, cover for sepsis

Congestive Heart Failure

• Present 2^nd to 6^th month
• Presents with respiratory symptoms (wheezing, retractions, tachypnea)
• Difficulty with feeding (the infant stress test)
• Treatment: Supportive

 Tetrology of Fallot

1. Calm the child, knee to chest
2. O₂ = reduction in PVR
3. Analgesia: morphine 0.1mg/kg, fentanyl 1.5 mcg/kg, ketamine 0.25 mg/kg
4. Establish Access: 10-20cc/kg bolus
5. Phenylephrine 0.2 mg/kg IV (to increase SVR)
6. +/- HCO₃ 1mmol/kg (if acidosis)
7. +/- beta blocker (with cardiology consultation)
8. PGE₁ 0.05mcg/kg/min titrating to 0.1mcg/kg/min

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Dermatology

Slapped Cheek/5^th Disease

• Parvo B19
• Slapped cheeks, lacy reticular pattern of rash on body
• Complications:
  • Pregnancy hydrops
  • Sickle Cell Disease  aplastic crisis

Measles

• Koplik spots, conjunctivitis, fever
• Can cause blindness

VZV

• Different stages of development
• Treat with acyclovir if > 12 years old
• Give VZIG in neonates and immunocompromised

Scarlet Fever

• Erythematous rash, palatal petechiae, pastia’s lines
• Strawberry tongue
• Trunk to periphery
• Treat with Pen VK: 50mg/kg BID x10d or Amox 20mg/kg BID x10d
• Pen allergic: Azithro 10mg/kg day 1 then 5mg/kg 2-5

Staphylococcal Scalded Skin Syndrome

• Toxin mediated, negative Nikolsky, good prognosis
• Treatment: Anti-staphylococcal antibiotics
  • Nafcillin 25mg/kg/d IV
  • Augmentin 45mg/kg/d PO in 2 divdied doses 7-10d
  • Keflex 10mg/kg/d QID x7-10d

Henoch-Schonlein Purpura

• Palpable purpura in dependent areas
• Arthralgia/Arthritis (50-84%)
• Abdominal pain (50%): vascular lesions in bowel, may be intussusception lead point
• Renal Disease (20-50%) may develop within 2 months
• Treatment: Supportive, NSAIDs

Kawasaki Disease

• 5 days of fever + 4/5 of criteria
  • Diffuse polymorphous diffuse rash
  • Conjunctivitis
  • Mucous membrane change (strawberry tongue)
  • Cervical LAD (usually unilateral)
  • Extremity changes
• Incomplete and atypical forms more common in infants
• Treatment (drop complications from 25% to 4-5%)
  • Aspirin 20mg/kg/dose Q6H
  • IVIG 2gm/kg over 12H

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Gastroenterology

Bilious Vomiting

• Bilious vomiting malrotation with volvulus until proven otherwise  surgical emergency
• 1^st month of life “pre-verbal child’s disease”
• Dx: Upper GI Series (10-15%) false positive rate

Necrotizing Enterocolitis

• 10% of cases full term
• XR w/ pneumatosis intestinalis

Hirschsprung’s

• No meconium, slightly distended abdomen
• Less severe  later presentation, p/w constipation

Pyloric Stenosis

• Presents around 6 wks: vomiting but very hungry
• Diagnosis
  • US pylorus > 4mm thick, >15mm long
  • NGT aspiration 5cc is abnormal
• Treatment
  • Resuscitate
  • Correct metabolic abnormalities
  • Consult surgery

Intussusception

• Most common infant emergency
  • 3 months – 2 years
• Abdominal pain, currant jelly, palpable mass (30% only)
• Typical presentation
  • Lethargy (may be only sign)
  • Vomiting
  • Paroxysms of pain
  • SBO
  • PO intolerance
• Diagnosis: US
• Treatment: Enema (80-95% successful), 10% recurrence

Meckel’s Diverticulum

• Around 2 years of age, boys > girls
• Obstruction, intussusception
• Diagnose with technetium scan

Appendicitis

• 1/3^rd with vomiting and diarrhea (AGE-type syndrome)

Hemolytic Uremic Syndrome

• Watery/bloody diarrhea
• Three components
  • Acute renal failure
  • Thrombocytopenia
  • Microangiopathic hemolytic anemia (MAHA)
• Signs
  • Pallor
  • Abdominal Pain
  • Decreased urine output
  • Low energy/AMS
  • Hypertension
  • Edema
  • Petechiae
  • Icterus
• Treatment: Supportive vs. Dialysis (50%)

GI Bleed by Age

Age	Well-Appearing	Ill-Appearing
Neonate	Allergic Proctocolitis	Malrotation with Volvulus
	Anal Fissure	Necrotizing Enterocolitis
	Swallowed Maternal Blood	Coagulopathy
Infant/Young Child	Allergic Proctocolitis	Meckel’s
	Gastritis	Intussusception
	Infectious Colitis	Vascular Malformation
Older Child/Adolescent	Gastritis	IBD
	Esophageal Bleeding	Cryptic Liver Disease
	Juvenile Polyps	Intestinal Ulceration

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Congenital Disorders

Congenital Adrenal Hyperplasia

• Presents in first two weeks of life
• Chief complaint may be vomiting
• Lyte: HyperK, HypoNa, Hypoglycemia  dysrhythmias, seizures
• Treatment
  • IVF (usual dose)
  • Glucose (usual dose)
  • Hydrocortisone: 25mg (neonate/infant), 50mg child, adolescent/adult 100mg

Inborn Errors of Metabolism

• Possible CC: Vomiting, Lethargy, Seizures, Hepatomegaly, Metab Acidosis, Odor
• May have normal labs and imaging
• Life-threatening: Metabolic acidosis, Hypoglycemia, Hyperammonemia, Sepsis
• Labs
  • VBG (acidosis),
  • CMP (liver, kidney, anion gap)
  • Ammonia, lactate, urine (ketones, reducing substance)
  • Bunch of extra tubes for labs later
• Treatment
  • NPO
  • IVF bolus
  • D10 at 1.5x maintenance
  • Treat Sepsis
  • Control seizures PRN, correct hyperammonemia/acid/lyte (may need dialysis)

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Pulmonary

Croup

• Toddlers (6-24 months), 5% of all children, boys > girls
  • PIV #1
  • Rhinovirus, Metapneumovirus, PIV II-IV, RSV, Flu A/B
  • Frequent co-infections with one or more viruses

• Sx: 1-3 days of URI Sx  Abrupt cough/stridor worse for one day, then better
• Signs: Nontoxic, if wheezing likely RSV
• Studies: XR to r/o FB (steeple sign if positive)
• Treatment: Racemic Epi: 0.25-0.75 cc in 3 cc Q 20 minutes, lasts < 2 hours
• Disposition: If stridor at rest then treat if no improvement, then admit

Stridor	Steroids	Racemic Epi	Dispo
Mild	0.15 mg/kg	No	Home
At rest with WOB	0.30 mg/kg	Yes	Admit
Severe at rest	0.60 mg/kg	Yes	ICU

Bronchiolitis

• Children < 2 years old, November through April (peak Jan/Feb)
  • Apnea in neonates and ex-premies < 2 months
  • Bacterial superinfection is very rare
• Presentation: Desat, tachypnea, nasal flaring, intercostal retractions, secretions
• Exam: Fine rales, diffuse/fine wheezing
• Treatment: Suction, O2 (if < 90%), NPPV
• Maybe albuterol, but no steroids/epi/abx

Epiglottitis

• Bimodal (2-6, 20-40y), < 1% URI with stridor, boys = girls, al year
  • Non-typable H.flu, staph/strep, Moraxella
  • Candida, HSV, VZV, crack cocaine
• Symptoms: Muffled voice, drooling rapid progression in hours
• Signs: No pharyngeal findings with severely tender anterior neck
• Studies: XR w/ thumb sign
• Treatment: Laryngoscopy, airway management

Bacterial Tracheitis

• Preschool (1-10y), boys = girls, Downs
• Symptoms: Several days’ URI  toxic in hours, rapid progression
• Signs: Subglottic diffuse inflammation, edema with exudates and pseudomembranes
• Studies: CXR demonstrates narrow trachea
• Treatment: Emergent intubation, 3^rd generation cephalosporin