Paeds

RA

2.2/1000

-Onset at age <16
-Duration >=6 weeks
-Exclusion of other arthritis

NONE

Fever and pin point bone tenderness

X-rays normal early, bone scan or MRI helpful

-Painful, swollen joints of feet and hands
-Bright red "slapped cheeks"
-Adolescence

Rash and arthritis due to immunological rxn, not infection itself

-2 weeks after Gp A strep (sore throat and fever)
-Can get arthritis without carditis
-Responds well to NSAIDs
-Major disease: Subcut nodules Pancarditis Arthritis Chorea Erythema marginatum

-Arthritis 1-3 weeks after infection at another site
-Joint fluid sterile
-Gp A strep or enteric (e.g. Salmonella)

-2 weeks after sore throat and fever (gp A strep)
-Can get arthritis without anyother features
SPACE
-Subcut nodules
-Pancarditis
-Arthritis
-Chorea
-Erythema marginatum

-Responds well to NSAIDs

Systemic: leukaemia, lymphoma and neuroblastoma

Local: osteoid osteoma, eosinophillic granuloma, sarcoma

-Fever, weight loss
-Pain >> physical findings
-Night pain
-Hepatosplenomegaly
-Lymphadenopathy
-Anaemia
-Metaphyseal lucency

Little leaguer's elbow, swimmer's shoulder, avascular necrosis of the femoral head, slipped capital femoral epiphysis

Transient synovitis
-May follow viral infection
-Benign course
-Normal x-ray
-Slight effusion on u/s

Legg-Perthe's
-Avascular necrosis of the femoral head
-More common in boys
-Decreased ROM (red flag)
-X-ray: sclerosis, loss of height in femoral head

Slipped capital femoral epiphysis
-Older boys, obese
-Stand with leg slightly externally rotated
-Fracture through growth plate

-No relation to growth
-Age 3-10
-Usually limited to calf, thigh, shins
-Occurs at night (fine next morning)
-Normal physical exam and tests

- Systemic arthritis (e.g. Still's disease): 10%
- Oligoarticular arthritis (<4 joints) 50%
- Polyarthritis (>4 joints) 30%
- Enthesitis related
- Psoriatic arthritis
- Unclassified

M=F
- Fever (spikes irregularly but returns to normal between spikes)
- Rash (salmon pink that comes and goes)
- Arthritis
- Hepatosplenomegaly
- Lymphadenopathy
- Serositis (pericarditis)
- Anaemia, high ESR, CRP, platelets

- Age < 5 years
- Girls > boys
- Large joints (knee most common)
- ANA =ve in 80%

- Knee flexion contracture
- Quadriceps atrophy
- Leg-length discrepancy
- Uveitis (in 20%, ass'd with +ve ANA, assymptomatic but if untreated blindness in 2-3%. Does not parallel disease course so screen every 3-4 months)

- Young girls > boys
- Small and large joints, neck, TMJs
- Uveitis in 10%
- Cervical spine arthritis
- Growth disturbance (small jaw)

- Older girls
- Symmetrical large and small joint arthritis
- Rheumatoid nodules over pressure points in 30%
- ANA may be +ve

- Older boys >> girls
- PHx
- Peripheral and axial arthritis
- Absent ANA and RF
- HLA B27 +ve
- Enthesitis

Leukocytoclastic vasculitis

- Small vessel vasculitis
- Affects skin, joints, GI tract, kidneys
- Acute morbidity from GI complications (bleeding, intusseception)
- Chronic morbidity related to end-stage renal disease
- Can get acute scrotum, penis and abdomen

Must have 2/4 of:
- Palpable purpura
- Age <20 at onset
- Bowel angina (after meals)
- Granulocytes in walls of arterioles or venules on biopsy

- Not related to malignancy
- Bright signal on MRI
- Muscle weakness
- Dilated capillary loops at the base of the fingernails
- Gottren's papules (on knuckles)

- Bands of thickened skin that run down a limb
- Can cause significant limitation of motion
- Patches on skin

- Butterfly rash on nasolabial folds
- Palatial ulceration
- +/- vasculitis (immune deposits)
- weight loss, night sweats, lethargy common

- 20% of all cases commence at age <18 years
- Commoner in blacks, hispanics and asians
- F:M 4.5:1

1. Assess severity
2. Achieve best lung function
3. Maintain best lung function (triggers)
4. Maintain best lung function (meds)
5. Develop an asthma action plan
6. Educate and review

Pulse
- Mild <100
- Moderate 100-200
- Severe >200
SaO2
- Mild >94%
- Moderate 90-94%
- Severe <90%

Central syanosis in severe only

An anticholinergic drug. It blocks the muscarinic cholinergic receptors in the smooth muscles of the bronchi in the lungs

- IV bolus or infusion of salbutamol
- Magnesium sulphate bolus (a smooth muscle relaxant)
- Aminophylline (loading and infusion) rarely used
- Anaesthetic agents and muscle relaxants
- CPAP
- Intubation and ventillation

- "stretch" ventolin
- Wean O2

- Covers 3-5 days
- # of puffs and frequency of reliever
- Oral steroid doses (mls)
- Time until reviewed by GP

- Infrequent intermittant (75%)
- Frequent intermittant (20%)
- Persistent (mild, mod, severe) 5%

4-6 years

- How often is sleep disturbed due to asthma?
- Is reliever used on waking?
- Does asthma limit exercise?
- How often in reliever used?
- How long does the reliever last?
- How much school has your chils missed due to asthma?

- Spirometry if old enough
- Possibly skin prick testing
- Chest x-ray possibly if 1st presentation

- Regular use of preventer
- How to increase reliever in response to symptoms
- How to access medical care

Evidence: improved adherence, decreased hospitalisation

Trauma. Blunt injury commonly.
Falls and sporting injuries are commonest followed by MVAs
Home is the commonest place of injury

Prevention

- Relatively bigger heads and organs
- Bones pliable (intrathoracic injury without fracture)
- Refuse to communicate when injured
- Small child: abdo injury in MVA
- Non-compliance and peer pressure re: safety devices

- Big occiput (put blanket under shoulders to avoid flexing head, or used paeds spinal board)
- Short neck
- Loose soft tissue swells a lot when burned
- Short trachea (tube often inserted too far)
- Crico-thyroidotomy difficult due to small membrane (if no other options use a needle and high pressure O2 but only works for 15min due to hypercarbia)

- Child's chest wall is thinner: difficult to localise added sounds
- Ribs more horizontal in younger children (less chest expansion)
- Crying: air filled stomach pushes up on diaphragm
- Infant RR 40-60/min
- Tidal volume 7-10mL/kg

- Early signs of shock when ~1/4 blood loss (tachycardia)
- Shock can mimic head injury
- Pulse pressure initially narrows, then widens late
- Hypotension = 45% loss of volume

- Give bolus of 20mL/kg
- Don't overresuscitate in penetrating injury
- Start with normal saline or Hartmann's
- Give 3 x crystalloid then blood
- Remember BSL in infants

- Blood volume 80mL/kg
- Systolic BP = 80 + 2x age in years
- Diastolic = 2/3 x systolic

- Difficult to assess in children
- AVPU used (if P, GCS = 9)
- Children have thin cranial bones

- Head to foot exam
- AMPLE Hx (allergies, medications, past MHx, last meal, events surrounding)
- Imaging (additional apart from trauma series)
- Consider transfer early

- Flexion fracture of the spine
- Usually T12-L2
- Check for hollow viscus injury if present

- Usually blunt
- Children have thin abdo wall and an abdominal bladder
- FAST: fluid +stable = CT, fluid + unstable = surgery
- Spare spleen if stable
- Handlebar injuries surprisingly serious (and seatbelt)

- Commonest cause of death
- Maintain ABCs: most important in preventing secondary injury

- Uncommon
- Most invasive Rx is likely to be a chest train
- Consider lung contusion in the absence of fracture

- 50% of all illnesess in age <5
- 30% in 5-12
- 95% of these URTIs
- LRTI: early life and boys

- Colds/coryza
- Pharyngitis
- Tonsillitis
- Otitis media
- Sinusitis

- Laryngo tracheobronchitis
- Epiglottitis
- Acute bronchitis
- Acute bronchiolitis
- Pneumonia

- 90%
- Rhinovirus
- Respiratory syncitial virus
- Parainfluenza types 1, 2 & 3
- Influenza types a & b
- Adenovirus
- Metapneumovirus

- 10%
- Beta-haemolytic streptococcus
- Streptococcus pneumoniae
- Haemophillus influenzae
- Staphlococcus aureus
- Mycoplasma pneumoniae, Chlamydia, pneumoniae, Leigonella

- Purpuric rash
- Bulging fontanelle
- Biphasic stridor
- High-pitched scream
- Bile-stained vomit
- Persistent tachycardia
- Grunting respiration

A: airway, alertness, activity
B: breathing difficulty
C: circulatory impairment
D: daily fluid balance (input & output)

- Flexing of arms and wrists
- Suggests lesion is above the brainstem

- Extension at elbows and flexion at wrists
- Suggests midbrain or pontine lesion

- Grunting
- Audible inspiratory/expiratory noises
- Nasal flare
- Recession
- Accessory muscle use
- Respiratory rate
- Head bobbing