BODY TEMPERATURE

Subnormal
Normal
Subfebrile
Fever
High fever
Hyperpyrexia

ABG

<36.6C
37.4C
35.7 38.0C
38.0C
>39.5C
>42.0C

AGE

HR (bpm)

BP (mmHg)

Preterm
Term
0-3 mo
3-6 mo
6-12 mo
1-3 yrs
3-6 yrs
6-12 yrs
12-17 yrs

120-170
120-160
100-150
90-120
80-120
70-110
65-110
60-95
55-85

55-75/35-45
65-85/45-55
65-85/45-55
70-90/50-65
80-100/55-65
90-105/55-70
95-110/60-75
100-120/60-75
110-135/65-85

pH:
pCO2:
pO2:

RR (cpm)
40-70
30-60
35-55
30-45
25-40
20-30
20-25
14-22
12-18

RBC

NB
4.8-7.1

Infant
3.8-5.5

WBC
PMNs
Lymph
Hgb

9-30,000
61%
31%
14-24

6-17,500
61%
32%
11-20

Hct

44-64%

35-49

Platelets 140-300 200-423

Ret
2.6-6.5 0.5-3.1

22-26mEq/L
+/- 2mEq/L
97%

Child
3.8-5.

Adole
M: 4.6-6.2
F: 4.2-5.4
5-10,000 6-10,000
60%
60%
30%
30%
11-16
M: 14-18
F: 12-16
31-46
M: 40-54
F: 37-47
150-450 150-450
0-2
0-2

IDEAL BODY WEIGHT

Age
At Birth

BT
CT
PTT

Caucasian
<18.5
18.5 24.9
25 29.9

1-5 min 1-6

5-8 min 5-8
12-20sec 12-14

1-6
5-8
12-14

Kilograms
3kg (Fil)
3.35kg (Cau)
Age (mo) + 9 / 2

3-12
mo
1-6 y
7-12 y

Pounds
7
Age (mo) + 10 (F)
Age (mo) + 11 (C)
Age (y) x 5 + 17
Age (y) x 7 + 5

Age (y) x 2 + 8
Age (y) x 7 5 / 2

Given Birth Weight:

Age
Using Birth Weight in Grams
< 6 mo
Age (mo) x 600 + birth weight (gm)
6-12 mo
Age (mo) x 500 + birth weight (gm)
Expected Body Weight (EBW):
Term
Age in days 10 x 20 + Birth Weight
Pre-Term
Age in days 14 x 15 + Birth Weight

COUNT (%)

BMI
Asian
<18.5
18.5 22.9
23.0
23 24.9
25 29.9
30

HCO3:
B.E.:
O2 sat:

NORMAL LABORATORY VALUES

BP cuff should cover 2/3 of arm

-: SMALL cuff:
falsely high BP
-: LARGE cuff:
falsely low BP

Underweight
Normal
Overweight
at risk
Obese I
Obese II

7.35-7.45
35-45
80-100

ANTHROPOMETRIC MEASUREMENTS

Age of Infant
4-5 months
1 year
2 years
3 years
5 years
7 years
10 years

1-6
5-8
12-14

Ideal Weight
2 x Birth Weight
3 x Birth Weight
4 x Birth Weight
5 x Birth Weight
6 x Birth Weight
7 x Birth Weight
10 x Birth Weight

30 39.9
>40
APGAR

LENGTH / HEIGHT
(50 cm)
Age
At Birth
1y
2-12 mo

Centimeters
50
75
Age x 6 + 77

Age
Inches
20
30
Age x 2.5 + 30

Transverse-AP
Diameter ratio
1.0
1.25
1.35

At Birth
1y
6y

Inches
Transverse = AP
Transverse > AP
Transverse >>> AP

FONTANELS
Gain in 1st Year is ~ 25cm
+ 9 cm
3 cm per mo
+ 8 cm
2.67 per mo
+ 5 cm
1.6 cm per mo
+ 3 cm
1 cm per mo

Age
0-3 mo
3-6 mo
6-9 mo
9-12 mo

Appropriate size at birth:

Closes at:
Anterior

Age
At Birth
< 4 mo

Inches
35 cm (13.8 in)
+ 2 in
(1/2 inches / mo)
+ 2 in
(1/4 inches / mo)
+ 1 inch
+ 1.5 in
(1/2 inches / year)
+ 1.5 in
(1/2 inches / year)

5-12 mo
1-2 yrs
3-5 yrs
6-20 yrs

TI =

+ 5.08cm
(1.27cm / mo)
+ 5.08cm
(0.635cm / mo)
2.54 cm
+ 3.81cm
(1.27cm / mo)
+ 3.81cm
(1.27cm / mo)

AGE
Birth
or 6 wks

DPT

6 wks

DOSE
0.05mL
(NB)
0.1mL
(older)
0.5mL

OPV
HEPA B

6 wks
6 wks

2 drops
0.5mL

3
3

PO
IM

MEASLES

9 mos

0.5mL

SC

BCG-2

School entry

0.1mL

ID

TetToxoid

Childbearing
women

0.5mL

IM

ROUTE
ID

SITE
RDeltoid

IM

Upper
Outer
thigh
Mouth
Anterolateral
thigh
Outer
upper
arm
LDeltoid
Deltoid

Safety
Use seatbelts/helmets?
Enter into high risk situations?
Member of frat/sorority/orgs?
Firearm at home?
F.R.I.C.H.M.O.N.D.

Fluids
Respiration
Infection
Cardiac
Hematologic
Metabolic
Output & Input [cc/kg/h] N: 1-2

(-)
Movement

Some flexion /
extension

Absent

Slow / Irregular

transverse chest diameter

AP diameter
Birth
1 year
6 years

Verbal

Infants/Young
4- Spontaneous
3- To speech
2- To pain
1- None
5- Appropriate
4- Inconsolable
3- Irritable
2- Moans
1- None
6- Spontaneous
5- Localize pain
4- Withdraw
3- Flexion
2- Extension
1- None

GCS

: 1.0
: 1.25
: 1.35

Older
Spontaneous
To speech
To pain
None
Oriented
Confused
Inappropriate
Incomprehensible
None
Spontaneous
Localize pain
Withdraw
Flexion
Extension
None

ADVERSE REACTIONS FROM VACCINES

INTERVAL

BCG

DPT
OPV
HEPA B
MEASLES

4 wks
4 wks

1. Wheal small abscess ulceration healing / scar formation in

12 wks
2. Deep abscess formation, indolent ulceration, glandular enlargement,
suppurative lymphadenitis
1. Fever, local soreness
2. Convulsions, encephalitis / encephalopathy, permanent brain
damage
Paralytic Polio
Local soreness
1. Fever & mild rash
2. Convulsions, encephalitis / encephalopathy, SSPE, death

4 wks

1 mo then
6-12 mos

H.E.A.D.S.S.S.

Suicide/Depression
Ever sad/tearful/unmotivated/hopeless?
Thought of hurting self/others?
Suicide plans?

Grimaces

Motor

#
1

Sexual activities
Sexual orientation?
GF/BF? Typical date?
Sexually active? When started? # of persons?
Contraceptives? Pregnancies? STDs?

(-)
Response

Function
Eye
Opening

EXPANDED PROGRAM ON IMMUNIZATION

VACCINE
BCG-1

2
Completely
pink
> 100
Coughs,
Sneezes,
Cries
Active
movement
Good, strong
cry

Normal
Mild / Moderate Asphyxia
Severe asphyxia

THORACIC INDEX

Centimeters

1
Pink body/ Blue
extremities
Slow (<100)

8 10:
4 7:
0 3:

Posterior

HEAD CIRCUMFERENCE
(33-38 cms)

2 x 2 cm (anterior)
= 18 months, or as early
as 9-12 months
= 6 8 weeks or
2 4 months

0
Blue /
Pale
Absent

H.E.A.D.S.S.S.
Home Environment

With whom does the adolescent live?

Any recent changes in the living

situation?

How are things among siblings?

Are parents employed?

Are there things in the family he/she

wants to change?
Employment and Education

Currently at school? Favorite subjects?

Patient performing academically?

Have been truant / expelled from

school?

Problems with classmates/teachers?

Currently employed?

Future education/employment goals?

Activities

Drugs

What he/she does in spare time?

Patient does for fun?
Whom does patient spend spare time?
Hobbies, interests, close friends?

Used tobacco/alcohol/steroids?
Illicit drugs? Frequency? Amount?
Affected daily activities?
Still using? Friends using/selling?

ACTIVE
BCG
DPT
OPV
Hep B
Measles
Hib
MMR
Tetanus Toxoid
Varicella

PASSIVE
Diphtheria
Tetanus
Tetanus Ig
Measles Ig
Rabies (HRIg)
Hep A Ig
Hep B ig
Rubella Ig

NUTRITION

AGE
0-5 mo
8-11 mo
1-2 y
3-6 y
7-9 y
10-12 y
13-15 y
16-19 y

WT.
3-6
7-9
10-12
14-18
22-24
28-32
36-44
48-55

TCR
TCR

CAL
115
110
110
90-100
80-90
70-80
55-65
45-50

CHON
3.5
3.0
2.5
2.0
1.5
1.5
1.5
1.2

= Wt at p50 x calories
= CHON X ABW

Total Caloric Intake

: calories X amount of
intake (oz)

Gastric Capacity

: age in months + 2

Gastric Emptying Time

: 2-3 hours

1:1
Alacta
Enfalac
Lactogen
Lactum
Nan
Nestogen
Nutraminogen
Pelargon
Prosobee

1:2
Bonna
Nursoy
Promil
S-26
Similac
SMA

THE SEVEN HABITS OF

HIGHLY EFFECTIVE PEOPLE
by Stephen R. Covey

Habit 1:
Habit 2:
Habit 3:
Habit 4:
Habit 5:

Be Proactive
Begin with the end in mind
Put First Things First
Think Win-Win
Seek first to understand and
then to be understood
Habit 6: Synergize
Habit 7: Sharpen the saw

EXPECTED LA SALLIAN
GRADUATE ATTRIBUTES
(ELGA)
1.
2.

Competent & safe physicians

Ethical & socially responsible
Doctors / practitioners
3.
Reflective lifelong learners
4.
Effective communicators
5.
Efficient & innovative managers

TREATMENT PLAN A
ACUTE DIARRHEA (at least 3x BM in 24 hrs)
4 Rules of Home Treatment

DIARRHEA

Chronic
: >14 days, non-infectious causes
Persistent : >14 days, infectious cause

ORS vol. after each loose stool 1 day

<24 mo
2-10 y.o.
>10 y.o.

5-100mL
100-200mL
As much as wanted

500mL
1000mL
2000mL

For severe dehydration / WHO hydration

(fluid: PLR 100cc/kg)
Age
<12
>12

30mL/kg
1H
30 mins

75mL/kg
5H
2H

Patient in SHOCK

20-30cc/kg IV fast drip

but in infants 10cc/kg IV (repeat if not stable)
If responsive & stable 75/kg x 4-6 hours

TREATMENT PLAN C
ETIOLOGY of AGE
Treat severe dehydration QUICKLY!
4 Major Mechanisms
Bacteria
Viruses
1.
Give extra fluid (as much as the child
Aeromonas Start IV fluid immediately Astroviruses
take)
1. will
Poorly
absorbed osmotically active substances in
Bacillus cereus
Caloviruses
lumen
Campylobacter
If jejuni
the child can drink, give Norovirus
ORS by
Breastfeed
frequently(increased)
& longer atoreach
feeding
2. >
Intestinal
ion secretion
decreased
Clostridium
perfringens
> if the child is exclusively breastfed, give one or
mouth while
the IV drip is beingEnteric
set up Adenovirus
absorption
Clostridium
difficile
Rotavirus
more of the
in addition
breastmilk
3. Outpouring
intofollowing
the lumen
of blood,tomucus
Escherichia coli
Cytomegalovirus
Give 100mL/kg Lactated
Ringers
ORS solution
4. Derangement
of intestinal motility
Plesiomonas
Herpes simplex virus
solution shigelbides
food based fluid (e.g. soup, rice, water)
Salmonella
clean water
TREATMENT
PLAN B
Shigella
First give
Then give
Rotaviral AGE (vomiting first then diarrhea)
Age
Staphylococcus
aureus
How much fluid to be given in addition to the usual
30mL/kg in:
70mL/kg in:
Recommended amount of ORS over 4 Vibrio
hour period
cholerae 01 & 0139
Ingestion
fluid intake?
of rotavirus rotavirus in intestinal villi
Infants
5 hours
Vibrio parahaemolyticus1 hour*
destruction of Age
villi up to:
4 mo 4 mo
12 mo
12(<12mo)
mo
2 yrs 2 yrs
5 yrs
Yersinia
enterocolitica
Up to 2 years:
50-100Wt:
mL after each
<6kg
6-9.9kgChildren 10-11.9kg
2-19kg
30 min*
2 hours
(secretory diarrhea absorption
loose
stool
secretion) AGE
(12mo-5yrs) 700-900
(mL)
200-400
400-700
900-1400
Parasites
Balantidium
coli
2 years or more:
140-200 mL
Use childs age only when weight is not
known
Blastocyctis
hominis
Assessment
:- give frequent
of dehydration
small sips (Skin
from aPinch
cup Test)
Repeat once if radial pulse is very weak or not
Approximate amount of ORS (mL)
Cryptosporidium
:- if the child vomits, wait for 10 min then
detectable
Giardia lamblia
(+) if >resume
2 seconds
CHILDS WT (kg) x 25
continue giving
fluids
until
diarrhea
no :-dehydration
if skinextra
tenting
goes
back
reassess the child every 15-30 min.
stops
if the child wants more ORS than shown, give more
Amoeba
Metronidazole
immediately
if dehydration
is not improving,
give frequent small sips from a cup
Al/mebendazol
give IVAscariasis
fluid more rapidly
2. Give Zinc supplements
if the child vomits, wait for 10 min then resume
e
continue breastfeeding whenever the child
wants
also
give
ORS
(~5mL/kg/hr)
as soon as the child
Cholera
Tetracyline
Up to 6 mo: 1 half tab per day for 10-14 days
can drink
[usually
after
3-4 hours in infants; 1-2
Shigella
TMP/SMX
6 months or more:
1 tab4 or
20mg
AFTER
HOURS
hours in children]
(Cotri)
OD x 10-14 days
reassess the child & classify dehydration status
Salmonella
Chloramphenic
reassess
after 6 hrs (infant)
& 3 hrs (child)
select the appropriate plan to continue treatment
ol
3. Continue feeding
begin feeding the child while at the clinic
4. Know when to return

1.
2.
3.

IV-FLUID COMPOSITIONS (Commonly Used for Infants and Child):

ORS

Glucose:
100mmol/L
Na:
60 mol/L
K:
20 mmol/L

Cl:
50mmol/L
Mg:
5mmol/L
Citrate:
10 mmol/L

Glucose:
111mmol/L
Na:
90 mmol/L
K:
20 mmol/L

Cl:
80mmol/L
HCO3:
5mmol/L

Glucose:
11mml/L
Na:
90 mmol/L
K:
20 mmol/L

Pedialyte 45 0r 90
-: prevention of DHN & to maintain normal
fluidelectrolyte balance in mild to moderate
dehydration.
Glucose 45mEq
Na: 20mEq
K: 35mEq
Citrate: 30mEq
Dextrose: 20g

Gluconate:
5mmol/L

Hydrite
-: 2 tab in 200ml water or 10sachets in 1L water
Child Age 2months up to 5years

ETIOLOGY OF PNEUMONIA

Glucolyte 60
-: for acute DHN secondary to GE or other forms
of diarrhea except CHOLERA. In burns, postsurgery replacement or maintenance, mild-salt
loosing syndrome, heat cramps and heat
exhaustion in adults.

Young Infants < 2months old

ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)

Glucose 90mEq
Na: 20mEq
K: 80mEq
Citrate: 30mEq
Dextrose: 25g

Pedialyte mild 30
-: to supplement fluid & electrolyte loss due to
active play, prolonged exposure, hot and humid
environment
Glucose: 30mEq
Na: 20mEq
K:
30mEq

Mg: 4mEq
lactate: 20mEq
Ca:
4mEq
Energy:
20kcal/ 100ml

Bacterial
- Streptococcus pneumoniae
- Group B streptococci
(neonates)
- Group A streptococci
- Mycoplasma pnemoniae
(adolescents)
- Chlamydia trachomatis
(infants)
- Mixed anearobes
(aspiration pneumonia)
- Gram negative enteric
(nosocomial pneumonia)
Viral
- Respiratory syncitial virus
- Parainfluenza type 1-3
- Influenza types A, B
- Adenovirus
- Metapneumovirus
Fungal
- Histoplasma capsulatum
- Cryptococcus neoformans
contact)
- Aspergillus sp.
(immunosuppressed)
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii

(Croup)

(bird, bat contact)

(bird
(immunosuppressed)
Mucormycosis

(immunosuppressed,
HIV, steroids)

SMR GIRLS
LUDANS METHOD (HYDRATION THERAPY)
MODERATE
DEHYRATION
100 cc/kg
60 cc/kg
st
1 hr: Plain LR
Next 5-7 hrs:
D5 0.3% in
5-7 hours

SEVERE
DEHYDRATION
150 cc/kg
90 cc/kg
st
1 hr: Plain LR
Next 5-7 hrs:
D5 0.3% in
5-7 hours

NOTE:

TOTAL FLUID REQUIREMENT

100 mL / kg
1000 + [ 50 for each kg in excess of 10 kg]
1500 + [ 20 for each kg in excess of 20 kg]

Computed Value is in mL/day

Ex. 25kg child
Answer: 1500 + [100] = 1600cc/day

ATYPICAL
DENGUE
PNEUMONIA
> MOT:
-:
extrpulmonary
mosquito
manifestations
bite
(man as reservior)
-: low grade fever
-: Vector:
>
patchy diffuse
Aedes
infiltrates
aegypti
-: poor response to Penicillin
-: Factors
>
negativeaffecting
sputum transmission:
gram stain
- breeding sites, high human population density,
mobile viremic human beings
Etiologic Agents Grouped by Age
> Age incidence peaks at 4-6 yrs
> Neonates (<1mo)
> -Incubation
GBS
period:
4-6 days
- E. coli
> -Serotypes:
other gram (-) bacilli
--Streptococcus
Type 2 most
pneumoniae
common
--Haemophilus
Types 1& 3 influenza (Type B)
- Type 4 least common but most severe
> 1-3 months
> *Main
Febrile
pathophysiologic
pneumonia changes:
a.- increase
RSV
in vascular permeability
- Other respiratory

viruses
- extravasation
Streptococcusofpneumoniae
plasma
- Haemophilus
- hemoconcentration
influenza (Type B)
- 3rd spacing of fluids
* Afebrile pneumonia
b.- abnormal
Chlamydiahemostasis
trachomatis
- -Mycoplasma
vasculopathyhomilis
- -CMV
thrombocytopenia
- coagulopathy

3
4
5

Breasts
Preadolescent
Breast & papilla elevated, as small
mound, areola diameter increased
Breast & areola enlarged, no contour
separation
Areola & papilla formed secondary
mound
Mature, nipple projects, areola part of
general breast contour

Darker, beginning to curl, amount

Course, curly, abundant but amount <
adult
Adult, feminine triangle, spread to
medial surface of thigh

SMR BOYS

HOLIDAY-SEGAR METHOD (MAINTENANCE)

WEIGHT
0 - 10 kg
11- 20 kg
> 20 kg

Pubic Hair
Preadolescent
Sparse, lightly pigmented, straight,
medial border of labia

Stage
1
2
3
4
5

Pubic Hair
None
Scanty, long slightly
pigmented
Darker, starts to curl, small
amount
Resembles adult type but
less in quantity, course,
curly
Adult distribution, spread
to medial surface of thigh

Dengue Fever Syndrome (DFS)

> 3-12 mo
Biphasic
- RSV fever (2-7 days) with 2 or more of the ff:
- Other respiratory viruses
1. -headache
Streptococcus pneumoniae
2. -myalgia
Haemophilus
or arthralgia
influenzae (Type B)
3. -retroorbital
C. trachomatis
pain
4. -hemorrhagic
M. pneumoniae
manifestations
-[petechiae,
Group A Streptococcus
purpura, (+) torniquet test]
5. leukopenia
> 2-5 yrs
- RSV Dengue Hemorrhagic Fever (DHF)
- Other respiratory viruses
1. -fever,
Streptococcus
persistently
pneumoniae
high grade (2-7 days)
2. -hemorrhagic
Haemophilusmanifestations
influenzae (Type B)
- -C.
(+)trachomatis
torniquet test
- -M.
petechiae,
pneumoniae
ecchymoses, purpura
- -Group
bleeding
A Streptococcus
from mucusa, GIT, puncture sites
- -Staph
melena,
aureus
hematemesis
3. Thrombocytopenia (< 100,000/mm3)
4.
> 2-5
Hemoconcentration
yrs
-- Streptococcus
hematocrit >40%
pneumoniae
or rise of >20% from baseline
-- Haemophilus
a drop in >20%
influenzae
Hct (from(Type
baseline)
B) following
- C. volume
trachomatis
replacement
-- M.
signs
pneumoniae
of plasma leakage
- Group
[pleuralAeffusion,
Streptococcus
ascites, hypoproteinemia]
- Staph aureus

Penis
Preadolescent
Slightly enlargement

Testes
Preadolescent
Enlarged scrotum, pink
texture altered

Longer

Larger

Larger, glans &

breadth in size

Larger, scrotum dark

Adult size

Adult size

Dengue Shock Syndrome

Manifestations of DHF plus signs of circulatory failure
1. rapid & weak pulse
2. narrow pulse pressure (<20mmHg)
3. hypotension for age
4. cold, clammy skin & irritability / restlessness
DANGER SIGNS OF DHF
DENGUE PATHOPHYSIOLOGY

< 15 kg, < 2 y/o

> 15 kg, 2 y/o

MILD
DEHYDRATION
50 cc/kg
30 cc/kg
D5 0.3% in
6-8 hours

Stage
1

1. abdominal pain (intense & sustained)

2. persistent vomiting
3. abrupt change from fever to hypothermia
with sweating
4. restlessness or somnolence
Grading of Dengue Hemorrhagic Fever

MANAGEMENT OF DENGUE

MANAGEMENT OF HEMORRHAGE

A. Vital Signs and Laboratory Monitoring

Monitor BP, Pulse Rate
We have to watch out for Shock (Hypotension)

Torniquet Test: SBP + DBP = mean BP for 5 mins.

ACUTE GLOMERULONEPHRITIS
2
Complications
if 20 petechial of
rash
AGN
per sq. inch on antecubital fossa
-(+)
CHF
test2 to fluid overload
- HPN encephalopathy
-Hermans
ARF due to
Rash:
GFR
- usually appears after fever lysed
- initially appears on the lower extremities
- not a common
STAGES
of AGNfinding among dengue patients
- Oliguric
an island
phase
of white
[7-10days]
in an oceanofcomplications
red
sets in
- Diuretic phase [7-10days]
recovery starts
- Convalescent phase [7-10days] patients are
B. Secondary Prevention
usually sent home
Recommended Guidelines for Transfusion:
Prognosis
Transfuse:
- Gross hematuria
2-3 weeks
-- PC
< 100,000 with signs of bleeding 3-6 weeks
Proteinuria
PC < 20,000 even if asymptomatic
-- C3
8-12 weeks
use FFP if without
overt bleeding
-- microscopic
hematuria
6-12 mo or
- FWB in cases with overt bleeding or 1-2 years
signs
of
hypovolemia
- HPN
4-6 weeks
C. Duration of Chemoprophylaxis
> if PT & PTT are abnormal: FFP
>
PTT only: cryprecipitate
> ifHyperkalemia
may be seen due to Na+ retention
> Ca++ decreases in PSAGN
3-7cc/kg/hr
depending on the Hct (1st no.) level
>
in ASO titer
(D5LR)
- normal within 2 weeks
10-20cc/kg
fast2drip
PLR - hypotension, narrow pulse
- peaks after
weeks
pressure
pulse
- more fair
pronounced
in pharyngeal infection
than in cutaneous
Leukopenia in dengue:
probable etiology is
Pseudomonas

URINARY
RHEUMATIC
TRACT FEVER
INFECTION
JONES CRITERIA:
Suggestive UTI:
A.
- Pyuria:
Major Manifestations
WBC 5/HPF or 10mm3
- Absence
- Carditisof pyuria doesnt rule out UTI (50-60%)
- Pyuria
- Polyarthritis
can be present w/o UTI
(70%)
- Chorea
(15-20%)
Presumptive
- Erythema Marginatum
UTI:
(3%)
- (-)
- Subcutaneous
urine culture Nodules
(1%)
- lower colony counts may be due to:
B.*Minor
overhydration
Manifestations
*- recent
Arthralgia
bladder emptying
*- previous
Fever antibiotic intake
- Laboratory Findings of:
Proven
Acute
or Confirmed
Phase Reactants
UTI:
(ESR / CRP)
- (+) urine
Prolonged
culturePR
100,000
interval cfu/mL urine of a single
organism
C.
- multiple
PLUS Supporting
organisms inEvidence
culture may
of Antecedent
indicate a
contaminated
Group-A Strep
sample
Infection
- (+) Throat Culture or Rapid Strep-Ag Test
- Rising Strep-AB Test

TREATMENT OF RHEUMATIC FEVER

A. Antibiotic Therapy
- 10 days of Oral Penicillin or Erythromycin
- IM Injection of Benzethine Penicillin
*** NOTE:

Sumapen

= Oral Penicillin!

B. Anti-Inflammatory Therapy
1. Aspirin (if Arthritis, NOT Carditis)
Acute: 100mg/kg/day in 4 doses x 3-5days
Then, 75mg/kg/day in 4 doses x 4 weeks
2. Prednisone
2mg/kg/day in 4 doses x 2-3weeks
Then, 5mg/24hrs every 2-3 days

PREVENTON
A. Primary Prevention
- 10 days of Oral Penicillin or Erythromycin
- IM Injection of Benzethine Penicillin

KAWASAKI DISEASE
TYPES OF SEIZURES
CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI
A. Partial Seizures (Focal / Local)
(ALL SHOULD BE PRESENT)
Simple Partial
Complex Partial
(Partial Seizure +
A) HIGH Grade Fever (>38.5 Rectally) PRESENT
Impaired Consciousness)
for AT LEAST 5-days without other Explanation
Partial Seizures evolving to Tonic-Clonic
High Grade Fever of at least 5 days
Convulsion
DOES NOT Respond to any kind of Antibiotic!
B. Generalized Seizures
B) Presence of 4 of the 5 Criteria
1. Bilateral
CONGESTION of
the mal)
Ocular Conjunctiva
Absence
(Petit
(seen
in 94%)
Myoclonic
2. Changes
Clonicof the Lips and Oral Cavity (At least ONE)
3. Changes
(At least ONE)
Tonic of the Extremities
4. Polymorphous
Exanthem
(92%)
Tonic-Clonic
5. Cervical
Adenopathy
=
Non-Suppurative
Cervical
Atonic
Adenopathy (should be >1.5cm) in 42%)

HARADA Criteria
SIMPLE FEBRILE SEIZURE
- used to determine whether
vs.IVIg should be given
- assessed COMPLEX
within 9 days
from onset
of illness
FEBRILE
SEIZURE
1. WBC > 12,000
2.
PC
<350,000
Febrile Seizure:
3. CRPin> 3+
A seizure
association with a febrile illness in the
4. Hctof
<35%
absence
a CNS infection or acute electrolyte
5.
Albumin
<3.5 g/dLolder than 1 month of age
imbalance in children
6. Age
monthsseizures
without
prior12afebrile
7. Gender: male

IVIg is given if 4 of 7 are fulfilled

If < 4 with continuing acute symptoms,
risk score must be reassessed daily

CLASSIFICATION
TREATMENT
BY CAUSE

SIMPLE SEIZURES
FEBRILE SEIZURE

A.
Currently
Acute Symptomatic
Recommended Protocol:
(shortly after an acute insult)
A. IV-Immunoglobulin
Infection
Hypoglycemia, low sodium, low calcium
2g/kg
Head
Regimen
trauma Infusion EQUALLY Effective in
Prevention
Toxic ingestion
of Aneurysms and Superior to 4-day
Regimen with respect to Amelioration of Inflammation
B. Remote Symptomatic
as measured by days of
Fever,
Pre-existing
ESR, CRP,brain
Platelet
abnormality
Count, Hgb,
or insult
and Albumin
Brain injury (head trauma, low oxygen)
NOTE:
Meningitis
There is a TIME FRAME of 10 days
Stroke
Tumor
B. Aspirin
Developmental brain abnormality

A. Criteria for an SFS

> Seizures:

sudden event <caused

15 minutes
by abrupt,

uncontrolled, hypersynchronous
Generalized-tonic-clonic

discharges of Fever
neurons
> 100.4 rectal to
101 F (38 to 38.4 C)
> Epilepsy:

tendency for recurrent

No recurrence
seizures
in 24
that
hours
are

unprovoked byNo
anpost-ictal
immediate
neuro
cause
abnormalities (e.g. Todds paresis)
> Status

epilepticus:
>30min
Most common
or back-to-back
6 months to
5 years
w/o return to baseline

Normal development
> Etiology:

No CNS infection or prior

- V ascular
afebrile seizures
:
AVM, stroke, hemorrhage
- I nfections
:
meningitis, encephalitis
-B.T Risk
raumatic
Factors:
- A utoimmune :
SLE,
Febrile
vasculitis,
seizure in
ADEM
1st / 2nd
- M etabolic
degree relative
:
electrolyte imbalance
- I diopathic

:
idiopathic
Neonatal nursery
epilepsy
stay of
- N eoplastic
>30 days :
space occupying lesion
- S tructural
:
cortical
Developmental
malformation,
delay

prior
Height
stroke
of temperature
- S yndrome
:
genetic disorder
C. Risk Factors for Epilepsy
(2 to 10% will go on to have epilepsy)

Developmental delay

Complex FS (possibly > 1

complex feature)

5% > 30 mins => _ of all

childhood status

Family History of Epilepsy

Duration of fever

C. HIGH
Idiopathic
Dose ASA (80-100mg/kg/day divided q 6h)
should
No history
be given
of Initially
preceding
in Conjunction
insult
with IV-IG
Likely genetic component
THEN
Reduced to Low Dose Aspirin (3-5mg/kg/day)
AND
Continued until Cardiac Evaluation COMPLETED
(approximately 1-2 months AFTER Onset of Disease)

BRONCHIAL ASTHMA (GINA GUIDELINES)

Day
symptoms
Limitation of
activities
Nocturnal Sx
(awakening)
Need for
reliever
Lung
function
Exacerbation

Controlled

Partly Controlled

none

> 2x per wk

none

any

none

any

< 2x per wk

> 2x per wk

normal

< 80%

none

> 1x per yr

Uncontrolled

3 or more symptoms
of Partly Controlled
Asthma in any week

1x / week

Clinical Features:
TUBERCULOSIS

RESPIRATORY DISTRESS SYNDROME

(Hyaline Membrane Disease)

A. Pulmonary TB
fully susceptible M. tuberculosis,
no history of previous anti-TB drugs
low local persistence of primary resistance to
Isoniazid (H)
2HRZ OD

then 4HR OD or 3x/wk DOT

Microbial susceptibility unknown or initial drug

resistance suspected (e.g. cavitary)
previous anti-TB use
close contact w/ resistant source case or living
in high areas w/ high pulmonary resistance to
H.

2HRZ + E/S
OD, then 4 HR + E/S OD or 3x/week DOT

o Male, preterm, low BW, maternal DM, & perinatal

asphyxia
o Corticosteroids:
most successful method to induce fetal lung
maturation
Administered 24-48 hours before delivery
decrease incidence of RDS
Most effective before 34 weeks AOG
o Microscopically: diffuse atelectasis, eosinophilic
membrane
Pathophysiology:
1.
2.

B.

Extrapulmonary TB
Same in PTB
For severe life threatening disease
(e.g. miliary, meningitis, bone, etc)

2HRZ + E/S OD, then 10HR + E/S OD

or 3x/wk DOT

Impaired/delayed surfactant synthesis &

secretion

3.
4.
5.
6.

V/Q (ventilation/perfusion) imbalance

due to deficiency of surfactant and decreased lung
compliance
Hypoxemia and systemic hypoperfusion
Respiratory and metabolic acidosis
Pulmonary vasoconstriction
Impaired endothelial &epithelial integrity

7.
8.

Proteinous exudates
RDS

1. Tachypnea, nasal flaring, subcostal and intercostal

retractions, cyanosis, grunting
2. Pallor
from anemia,
peripheral vasoconstriction
3. Onset
within 6 hours of life
Peak severity
2-3 days
Recovery
72 hours
Retractions:
o Due to (-) intrapleural pressure produced by
interaction b/w contraction of diaphragm & other
respiratory muscles and mechanical properties of
the lungs & chest wall
Nasal flaring:
o Due to contraction of alae nasi muscles leading to
marked reduction in nasal resistance
Grunting:
o Expiration through partially closed vocal cords
Initial expiration: glottis closed
lungs w/ gas
inc. transpulmo P w/o airflow
Last part of expiration: gas expelled against
partially closed cords
Cyanosis:

o Central

tongue & mnucosa (imp. Indicator of

impaired gas exchange); depends on
total amount of desaturated Hgb

UMBILICAL CATHERIZATION
NEWBORN RESUSCITATION
AIRWAY: open & clear
Positioning
Suctioning

Endotracheal intubation (if necessary)

BREATHING is spontaneous or assisted
Tactile stimulation (drying, rubbing)
Positive-pressure ventilation

CIRCULATION of oxygenated blood is adequate

Chest compressions
Medication and volume expansion

RESUSCITAION MEDICATIONS
Atropine
Bicarbonate
Calcium
Calcium chloride
Calcium gluconate
Dextrose
Epinephrine

0.02 ml/k IM, IV, ET

1-2 meq/k
10 mg elem Ca/k slow IV
0.33/k (27 mg Ca/cc)
1 cc/k (9 mg Ca/cc)
1g/k = 2 cc/k D50
4 cc/k D25
0.01 cc/k IV, ET

Cathether length
Standardize Graph
Perpedicular line from the tip of the shoulder to
the umbilicus
Measure length from Xiphoid to umbilicus and add
0.5 to 1cm.
Birth weight regression formula
Low line
: UA catheter in cm = BW + 7
High line
: UA catheter
= [3xBW] + 9
UV catheter length
= [0.5xhigh line] + 1

Indications
Vascular access (UV)
Blood Pressure (UA) and blood gas monitoring in
critically ill infants
Complications
Infection
Bleeding
Hemorrhage
Perforation of vessel
Thrombosis w/ distal embolization
Ischemia or infarction of lower extremities, bowel
or kidney
Arrhythmia
Air embolus

Procedure
Determine the length of the catheter
Restrain infant and prep the area using sterile
technique
Flush catheter with sterile saline solution
Place umbilical tape around the cord. Cut cord
about 1.5-2cm from the skin.
Identify the blood vessels.
(1thin=vein, 2thick=artery)
Grasp the catheter 1cm from the tip. Insert into the
vein, aiming toward the feet.
Secure the catheter
Observe for possible complications

Cautions
Never for:
Omphalitis
Peritonitis
Contraindicated in
NEC
Intestinal hypoperfusion
Line Placement
Arterial line
Low line
Tip lie above the bifurcation between L3 & L5
High line
Tip is above the diaphram between T6 & T9

BILIRUBIN
PRETERM:
0-1 hr
1-2 d
3-5 d

mg/dl
1-6
6-8
10-12

mmol/L
17-100
100-140
170-200

mg/dl
2-6
6-7
4-12
<1

mmol/L
34-100
100-120
70-200
<17

TERM
0-1 hr
1-2 d
3-5 d
1 mo

KRAMERS CLASSIFICATION OF JAUNDICE

ZONE

JAUNDICE

Head & neck

Upper trunk
to umbilicus
Lower trunk
to thigh
Arms, legs,
below
Hands & feet

II
III
IV
V

SERUM
BILIRUBIN
6-8
9-12
12-16
15
15