Pediatrics- Ward Notes (Part II)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:

Metabolic Profile Investigations:
ABG's, Urinary amino acid chromatography, Sugar chromatography, Serum ammonium levels

Subtle Seizures- lip smacking, cycling movements, repetitive swallowing. 50% of neonatal seizures are subtle.
Jitteriness is differentiated from seizures by physically holding the child's hands. If the movements stop, then it is considered to be Jitteriness. If the movements cannot be forced to stop, then it is a Seizure.
Jitteriness may be caused by hypocalcaemia or hypoglycemia.

ER management of Neonatal Seizures:
Establish and maintain Airway Breathing Circulation, I/V Dextrose for hypoglycemia, I/V calcium for hypocalcaemia, Drugs
Uncontrolled seizures may be controlled with- Paraldehyde (suppository), Pyridoxine (vitamin B6), Generalized anesthesia

Drugs for seizures should not be discontinued unless
there is a 2 year seizure free interval.
Teachers usually pick up Petit Mal seizures. Thus, counseling is necessary.

Risk factors for simple febrile fits developing into Epilepsy:
(bad prognostic signs)
Young age of onset, Abnormal development, Delayed milestones, Prolonged duration of fits, Increased frequency of fits, Family history of seizures.
There is a 10% chance that complex seizures will develop into Epilepsy.

Before making the diagnosis of Febrile Fits, make sure you check for the signs of underlying Meningitis and Encephalitis:
Meningitis- Bulging anterior fontanelle (this may be the only sign present in a 6 month old child), Brudzinski's sign +ve (involuntary flexion of the legs when the neck is placed in flexion), Kernig's sign +ve (flexion of the leg 90 degrees at the hip joint with pain on extension of the leg thereafter)
Encephalitis- Drowsiness, Increased tone, Babinski's sign +ve (fanning out of the toes with extension of the halux when a painful stimulus is applied)

Infantile spasm- West syndrome. “Salaam” posture. Flexion.

Side Effects:
Phenobarbitone- Irritability, Behavioral changes, Ataxia, Exfoliative dermatitis
Phenytoin- Gingival hyperplasia, Hepatotoxicity, Folate deficiency, Ricket's, Hypersensitivity, Steven Johnson syndrome
Tetracycline- discoloration of teeth
Co-Trimoxazole- Steven Johnson syndrome, bone marrow suppression
Chloramphenicol- aplastic anemia, bone marrow suppression, grey baby syndrome
Cyclophosphamide- Infertility, Alopecia, Bone marrow suppression, Hemorrhagic cystitis

D/D's for fits with CNS infection:
Meningitis, Encephalitis, Cerebral malaria, Tuberculosis, Otitis media, Brain abscess (focal lesion)

D/D's for Focal seizures without Fever:
Stroke, Thrombus, Cardiac defects (endocarditis, PDA, arrhythmias), Hypocalcaemia, Autoimmune, Coagulopathies, Dehydration (causes hyperviscosity and stasis of blood), Polycythemia

SIADH may lead to seizures via hyponatremia.

Diarrhea:
Chronic Diarrhea- Diarrhea for 2 weeks with no organism detected. Diarrhea is defined to be 2-3 episodes of loose watery stools more than usual.
Safe water- Water suitable for drinking that is free of bacteria/contaminants and has normal biochemical values.

Indications for antibiotics in acute watery diarrhea:
Blood in stool, Suspected cholera outbreak, Amebiasis, Giardiasis, Focus of infection is outside of the GIT

Risk Groups for Dehydration:
Children <1>5 diarrheal stools within the previous 24 hours, Malnutrition, Children who cannot tolerate ORS before presentation, Infants who stop breastfeeding during illness.

Complications of Diarrhea:
Dehydration, Hypovoluemic shock, Metabolic acidosis (bicarbonate in stool), Renal failure, Hypokalemia, Hyponatremia (seizures), Hypoglycemia, DIC, Aspiration pneumonia
Signs of Hypokalemia- Paralytic Ileus (post diarrheal dehydration), Muscle weakness, Arrhythmia, Sluggishness

Treat dehydration with Ringer's lactate 100 mL/kg/day.
For ongoing losses use 1/5th Dextrose saline 250 mL/kg/day.
Potassium is supplemented over a time frame of at least 6 hours. Otherwise, cerebral edema may occur.
Normal saline can be used to compensate for losses of Vomiting.
Daily Na+ requirement is 2-3 meq/kg.
Ringer’s lactate does not cause sodium excess. It expands the circulating volume and helps correct metabolic acidosis. Ringolactate D has the addition of 5% dextrose.

Metabolic acidosis causes a shift in Potassium ions. 40 mEQ is the maximum amount of Potassium put in I liter.
The addition of exogenous potassium causes a “layering effect” because potassium floats to the top of the solution. Potassium chloride is notorious for this effect. This is avoided by using Plabolyte, a homogenized solution in which every drop has the same solution.

Diarrhea presents with deep, rapid breathing. To collect a stool sample, ask the mother to flip the diaper inside out.
Post diarrheal distention is mainly Iatrogenic. Causes include unnecessary antibiotics in viral causes, and use of anti-motility drugs.
New ORS has an osmolarity of 245. Glucose 75, Sodium 75.

Hypernatremic Dehydration: Suspected when mothers incorrectly prepare ORS or powdered milk formulas. Present with Jittery movements, Increased muscle tone, Hyperreflexia, Convulsions, Coma.

KYB diet- Kichiri, Yogurt, Banana.


Pulsus Alternans- Left ventricular failure

Pulsus Paradoxus:
Cardiac- Pericar
dial effusion, Cardiac tamponade, Cardiogenic shock
Pulmonary- Pulmonary embolism, Asthma, COPD
Others- Superior vena caval obstruction, Anaphylactic shock

Waterhammer (collapsing) Pulse:
Physiologic- Fever, Pregnancy
Cardiac- Hypertension, Bradycardia, Aortic regurgitation, PDA
Others- Anemia, A/V fistula, Beri-beri deficiency, Cirrhosis, Cor pulmonale, Thyrotoxicosis
(Mnemonic for Others- AABCCT)


As this is a series, there will be more to come soon!

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