This document provides information on immunization schedules, vaccine doses and administration routes, common adverse reactions to vaccines, normal vital signs and anthropometric measurements for different age groups, and treatment plans for dehydration and diarrhea. The schedules include vaccines for BCG, DPT, OPV, hepatitis B, and measles, among others. Adverse reactions noted include fever, convulsions, and neurological effects. Guidelines are provided for weight, height, head circumference, chest and fontanel measurements, blood pressure, respiration rate, and temperature according to age.
This document provides information on immunization schedules, vaccine doses and administration routes, common adverse reactions to vaccines, normal vital signs and anthropometric measurements for different age groups, and treatment plans for dehydration and diarrhea. The schedules include vaccines for BCG, DPT, OPV, hepatitis B, and measles, among others. Adverse reactions noted include fever, convulsions, and neurological effects. Guidelines are provided for weight, height, head circumference, chest and fontanel measurements, blood pressure, respiration rate, and temperature according to age.
This document provides information on immunization schedules, vaccine doses and administration routes, common adverse reactions to vaccines, normal vital signs and anthropometric measurements for different age groups, and treatment plans for dehydration and diarrhea. The schedules include vaccines for BCG, DPT, OPV, hepatitis B, and measles, among others. Adverse reactions noted include fever, convulsions, and neurological effects. Guidelines are provided for weight, height, head circumference, chest and fontanel measurements, blood pressure, respiration rate, and temperature according to age.
This document provides information on immunization schedules, vaccine doses and administration routes, common adverse reactions to vaccines, normal vital signs and anthropometric measurements for different age groups, and treatment plans for dehydration and diarrhea. The schedules include vaccines for BCG, DPT, OPV, hepatitis B, and measles, among others. Adverse reactions noted include fever, convulsions, and neurological effects. Guidelines are provided for weight, height, head circumference, chest and fontanel measurements, blood pressure, respiration rate, and temperature according to age.
The document discusses various topics related to pediatric medicine including vaccination schedules, normal vital signs and lab values, anthropometric measurements, and procedures like lumbar puncture.
The different types of vaccines mentioned are BCG, DPT, OPV, Hepatitis B, Measles, Tetanus Toxoid. They are typically administered from birth up to school age based on the vaccination schedule.
Common adverse reactions from vaccines mentioned are fever, local soreness, convulsions, encephalitis, and paralysis. Reactions can range from mild to severe.
EXPANDED PROGRAM ON IMMUNIZATION
VACCINE AGE DOSE # ROUTE SITE INTERVAL
BCG-1 Birth or 6 wks 0.05mL (NB) 0.1mL (older) 1 ID R- Deltoid
DPT 6 wks 0.5mL 3 IM Upper Outer thigh
OPV 6 wks 2 drops 3 PO Mouth 4 wks HEPA B 6 wks 0.5mL 3 IM Antero- lateral thigh 4 wks MEASLES 9 mos 0.5mL 1 SC Outer upper arm 4 wks BCG-2 School entry 0.1mL 1 ID L- Deltoid
TetToxoid Childbearing women 0.5mL 3 IM Deltoid 1 mo then 6-12 mos
ADVERSE REACTIONS FROM VACCINES
BCG 1. Wheal small abscess ulceration healing / scar formation in 12 wks 2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis DPT 1. Fever, local soreness 2. Convulsions, encephalitis / encephalopathy, permanent brain damage OPV Paralytic Polio HEPA B Local soreness MEASLES 1. Fever & mild rash 2. Convulsions, encephalitis / encephalopathy, SSPE, death
ACTIVE PASSIVE BCG Diphtheria DPT Tetanus OPV Tetanus Ig Hep B Measles Ig Measles Rabies (HRIg) Hib Hep A Ig MMR Hep B ig Tetanus Toxoid Rubella Ig Varicella
BODY TEMPERATURE
Subnormal <36.6C Normal 37.4C Subfebrile 35.7 38.0C Fever 38.0C High fever >39.5C Hyperpyrexia >42.0C
BT 1-5 min 1-6 1-6 1-6 CT 5-8 min 5-8 5-8 5-8 PTT 12-20sec 12-14 12-14 12-14
ANTHROPOMETRIC MEASUREMENTS
IDEAL BODY WEIGHT
Age Kilograms Pounds At Birth 3kg (Fil) 3.35kg (Cau) 7 3-12 mo Age (mo) + 9 / 2 Age (mo) + 10 (F) Age (mo) + 11 (C) 1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17 7-12 y Age (y) x 7 5 / 2 Age (y) x 7 + 5
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
Age of Infant Ideal Weight 4-5 months 2 x Birth Weight 1 year 3 x Birth Weight 2 years 4 x Birth Weight 3 years 5 x Birth Weight 5 years 6 x Birth Weight 7 years 7 x Birth Weight 10 years 10 x Birth Weight
LENGTH / HEIGHT (50 cm)
Age Centimeters Inches At Birth 50 20 1 y 75 30 2-12 mo Age x 6 + 77 Age x 2.5 + 30
Age Gain in 1 st Year is ~ 25cm 0-3 mo + 9 cm 3 cm per mo 3-6 mo + 8 cm 2.67 per mo 6-9 mo + 5 cm 1.6 cm per mo 9-12 mo + 3 cm 1 cm per mo
HEAD CIRCUMFERENCE (33-38 cms)
Age Inches Centimeters At Birth 35 cm (13.8 in) < 4 mo + 2 in (1/2 inches / mo) + 5.08cm (1.27cm / mo) 5-12 mo + 2 in (1/4 inches / mo) + 5.08cm (0.635cm / mo) 1-2 yrs + 1 inch 2.54 cm 3-5 yrs + 1.5 in (1/2 inches / year) + 3.81cm (1.27cm / mo) 6-20 yrs + 1.5 in (1/2 inches / year) + 3.81cm (1.27cm / mo)
Age Transverse-AP Diameter ratio Inches At Birth 1.0 Transverse = AP 1 y 1.25 Transverse > AP 6 y 1.35 Transverse >>> AP
FONTANELS
Appropriate size at birth: 2 x 2 cm (anterior) Closes at: Anterior = 18 months, or as early as 9-12 months Posterior = 6 8 weeks or 2 4 months
THORACIC INDEX
TI = transverse chest diameter AP diameter
Birth : 1.0 1 year : 1.25 6 years : 1.35
APGAR
0 1 2 A Blue / Pale Pink body/ Blue extremities Completely pink P Absent Slow (<100) > 100 G (-) Response Grimaces Coughs, Sneezes, Cries A (-) Movement Some flexion / extension Active movement R Absent Slow / Irregular Good, strong cry
8 10: Normal 4 7: Mild / Moderate Asphyxia 0 3: Severe asphyxia
GCS
Function Infants/Young Older Eye Opening 4- Spontaneous 3- To speech 2- To pain 1- None Spontaneous To speech To pain None Verbal 5- Appropriate 4- Inconsolable 3- Irritable 2- Moans 1- None Oriented Confused Inappropriate Incomprehensible None Motor 6- Spontaneous 5- Localize pain 4- Withdraw 3- Flexion 2- Extension 1- None Spontaneous Localize pain Withdraw Flexion Extension None
H.E.A.D.S.S.S.
Sexual activities Sexual orientation? GF/BF? Typical date? Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs?
Suicide/Depression Ever sad/tearful/unmotivated/hopeless? Thought of hurting self/others? Suicide plans?
Safety Use seatbelts/helmets? Enter into high risk situations? Member of frat/sorority/orgs? Firearm at home?
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 What he/she does in spare time? Patient does for fun? Whom does patient spend spare time? Hobbies, interests, close friends?
Drugs Used tobacco/alcohol/steroids? Illicit drugs? Frequency? Amount? Affected daily activities? Still using? Friends using/selling?
NUTRITION
AGE WT. CAL CHON 0-5 mo 3-6 115 3.5 8-11 mo 7-9 110 3.0 1-2 y 10-12 110 2.5 3-6 y 14-18 90-100 2.0 7-9 y 22-24 80-90 1.5 10-12 y 28-32 70-80 1.5 13-15 y 36-44 55-65 1.5 16-19 y 48-55 45-50 1.2
TCR = Wt at p50 x calories TCR = 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 1:2 Alacta Bonna Enfalac Nursoy Lactogen Promil Lactum S-26 Nan Similac Nestogen SMA Nutraminogen Pelargon Prosobee
THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE by Stephen R. Covey
Habit 1: Be Proactive Habit 2: Begin with the end in mind Habit 3: Put First Things First Habit 4: Think Win-Win Habit 5: Seek first to understand and then to be understood Habit 6: Synergize Habit 7: Sharpen the saw
Age up to: 4 mo 4 mo 12 mo 12 mo 2 yrs 2 yrs 5 yrs Wt: <6kg 6-9.9kg 10-11.9kg 2-19kg (mL) 200-400 400-700 700-900 900-1400
Use childs age only when weight is not known Approximate amount of ORS (mL)
CHILDS WT (kg) x 25
if the child wants more ORS than shown, give more give frequent small sips from a cup if the child vomits, wait for 10 min then resume continue breastfeeding whenever the child wants
AFTER 4 HOURS reassess the child & classify dehydration status select the appropriate plan to continue treatment begin feeding the child while at the clinic
<24 mo 5-100mL 500mL 2-10 y.o. 100-200mL 1000mL >10 y.o. As much as wanted 2000mL
For severe dehydration / WHO hydration (fluid: PLR 100cc/kg)
Age 30mL/kg 75mL/kg <12 1H 5H >12 30 mins 2 H
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
ACUTE DIARRHEA (at least 3x BM in 24 hrs)
4 Major Mechanisms
1. Poorly absorbed osmotically active substances in lumen 2. Intestinal ion secretion (increased) or decreased absorption 3. Outpouring into the lumen of blood, mucus 4. Derangement of intestinal motility
Rotaviral AGE (vomiting first then diarrhea) Ingestion of rotavirus rotavirus in intestinal villi destruction of villi
(secretory diarrhea absorption secretion) AGE
Assessment of dehydration (Skin Pinch Test)
(+) if > 2 seconds no dehydration if skin tenting goes back immediately
1. Give extra fluid (as much as the child will take)
> Breastfeed frequently & longer at each feeding > if the child is exclusively breastfed, give one or more of the following in addition to breastmilk ORS solution food based fluid (e.g. soup, rice, water) clean water
How much fluid to be given in addition to the usual fluid intake?
Up to 2 years: 50-100 mL after each loose stool
2 years or more: 140-200 mL :- give frequent small sips from a cup :- if the child vomits, wait for 10 min then resume :- continue giving extra fluids until diarrhea stops
2. Give Zinc supplements
Up to 6 mo: 1 half tab per day for 10-14 days 6 months or more: 1 tab or 20mg OD x 10-14 days
3. Continue feeding 4. Know when to return
TREATMENT PLAN C
Treat severe dehydration QUICKLY!
1. Start IV fluid immediately 2. If the child can drink, give ORS by mouth while the IV drip is being set up 3. Give 100mL/kg Lactated Ringers solution
Age First give Then give 30mL/kg in: 70mL/kg in: Infants (<12mo) 1 hour* 5 hours Children (12mo-5yrs) 30 min* 2 hours
Repeat once if radial pulse is very weak or not detectable
reassess the child every 15-30 min. if dehydration is not improving, give IV fluid more rapidly
also give ORS (~5mL/kg/hr) as soon as the child can drink [usually after 3-4 hours in infants; 1-2 hours in children]
reassess after 6 hrs (infant) & 3 hrs (child)
SMR GIRLS Stage Pubic Hair Breasts 1 Preadolescent Preadolescent 2 Sparse, lightly pigmented, straight, medial border of labia Breast & papilla elevated, as small mound, areola diameter increased 3 Darker, beginning to curl, amount Breast & areola enlarged, no contour separation 4 Course, curly, abundant but amount < adult Areola & papilla formed secondary mound 5 Adult, feminine triangle, spread to medial surface of thigh Mature, nipple projects, areola part of general breast contour
SMR BOYS Stage Pubic Hair Penis Testes 1 None Preadolescent Preadolescent 2 Scanty, long slightly pigmented Slightly enlargement Enlarged scrotum, pink texture altered 3 Darker, starts to curl, small amount Longer Larger 4 Resembles adult type but less in quantity, course, curly Larger, glans & breadth in size Larger, scrotum dark 5 Adult distribution, spread to medial surface of thigh Adult size Adult size
ORS
Glucolyte 60 -: for acute DHN secondary to GE or other forms of diarrhea except CHOLERA. In burns, post- surgery replacement or maintenance, mild-salt loosing syndrome, heat cramps and heat exhaustion in adults.
MILD DEHYDRATION MODERATE DEHYRATION SEVERE DEHYDRATION < 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg > 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg D5 0.3% in 6-8 hours 1 st hr: Plain LR Next 5-7 hrs: D5 0.3% in 5-7 hours 1 st hr: Plain LR Next 5-7 hrs: D5 0.3% in 5-7 hours
HOLIDAY-SEGAR METHOD (MAINTENANCE)
WEIGHT TOTAL FLUID REQUIREMENT 0 - 10 kg 100 mL / kg 11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg] > 20 kg 1500 + [ 20 for each kg in excess of 20 kg]
NOTE: Computed Value is in mL/day Ex. 25kg child Answer: 1500 + [100] = 1600cc/day
> 3-12 mo - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus
> 2-5 yrs - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus
> 2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus
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
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
DENGUE
> MOT: mosquito bite (man as reservior)
> Vector: Aedes aegypti
> Factors affecting transmission: - breeding sites, high human population density, mobile viremic human beings
> Age incidence peaks at 4-6 yrs
> Incubation period: 4-6 days
> Serotypes: - Type 2 most common - Types 1& 3 - Type 4 least common but most severe
> Main pathophysiologic changes: a. increase in vascular permeability
extravasation of plasma - hemoconcentration - 3 rd spacing of fluids
b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy
Dengue Fever Syndrome (DFS)
Biphasic fever (2-7 days) with 2 or more of the ff:
1. fever, persistently high grade (2-7 days) 2. hemorrhagic manifestations - (+) torniquet test - petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis 3. Thrombocytopenia (< 100,000/mm 3 ) 4. Hemoconcentration - hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following volume replacement - signs of plasma leakage [pleural effusion, ascites, hypoproteinemia]
D E N G U E
P A T H O P H Y S I O L O G Y
MANAGEMENT OF DENGUE
A. Vital Signs and Laboratory Monitoring Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)
MANAGEMENT OF HEMORRHAGE
Torniquet Test: SBP + DBP = mean BP for 5 mins. 2
if 20 petechial rash per sq. inch on antecubital fossa (+) test
Hermans Rash: - usually appears after fever lysed - initially appears on the lower extremities - not a common finding among dengue patients - an island of white in an ocean of red
Recommended Guidelines for Transfusion:
Transfuse: - PC < 100,000 with signs of bleeding - PC < 20,000 even if asymptomatic - use FFP if without overt bleeding - FWB in cases with overt bleeding or signs of hypovolemia
> if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate
3-7cc/kg/hr depending on the Hct (1 st no.) level (D5LR) 10-20cc/kg fast drip PLR - hypotension, narrow pulse pressure fair pulse
Leukopenia in dengue: probable etiology is Pseudomonas
therefore: give Meropenem or Ceftazidime
URINARY TRACT INFECTION
Suggestive UTI: - Pyuria: WBC 5/HPF or 10mm 3
- Absence of pyuria doesnt rule out UTI - Pyuria can be present w/o UTI
Presumptive UTI: - (-) urine culture - lower colony counts may be due to: * overhydration * recent bladder emptying * previous antibiotic intake
Proven or Confirmed UTI: - (+) urine culture 100,000 cfu/mL urine of a single organism - multiple organisms in culture may indicate a contaminated sample
ACUTE GLOMERULONEPHRITIS
Complications of AGN - CHF 2 to fluid overload - HPN encephalopathy - ARF due to GFR
STAGES of AGN - Oliguric phase [7-10days] complications sets in - Diuretic phase [7-10days] recovery starts - Convalescent phase [7-10days] patients are usually sent home
Prognosis - Gross hematuria 2-3 weeks - Proteinuria 3-6 weeks - C3 8-12 weeks - microscopic hematuria 6-12 mo or 1-2 years - HPN 4-6 weeks
> Hyperkalemia may be seen due to Na + retention > Ca ++ decreases in PSAGN > in ASO titer - normal within 2 weeks - peaks after 2 weeks - more pronounced in pharyngeal infection than in cutaneous
RHEUMATIC FEVER
J ONES CRITERIA:
A. Major Manifestations - Carditis (50-60%) - Polyarthritis (70%) - Chorea (15-20%) - Erythema Marginatum (3%) - Subcutaneous Nodules (1%)
B. Minor Manifestations - Arthralgia - Fever - Laboratory Findings of: Acute Phase Reactants (ESR / CRP) Prolonged PR interval
C. PLUS Supporting Evidence of Antecedent Group-A Strep 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
B. Secondary Prevention
C. Duration of Chemoprophylaxis
KAWASAKI DISEASE
CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT)
A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation High Grade Fever of at least 5 days DOES NOT Respond to any kind of Antibiotic!
B) Presence of 4 of the 5 Criteria 1. Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%) 2. Changes of the Lips and Oral Cavity (At least ONE) 3. Changes of the Extremities (At least ONE) 4. Polymorphous Exanthem (92%) 5. Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%)
HARADA Criteria - used to determine whether IVIg should be given - assessed within 9 days from onset of illness 1. WBC > 12,000 2. PC <350,000 3. CRP > 3+ 4. Hct <35% 5. Albumin <3.5 g/dL 6. Age 12 months 7. Gender: male
IVIg is given if 4 of 7 are fulfilled If < 4 with continuing acute symptoms, risk score must be reassessed daily
TREATMENT
Currently Recommended Protocol:
A. IV-Immunoglobulin
2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation as measured by days of Fever, ESR, CRP, Platelet Count, Hgb, and Albumin
NOTE: There is a TIME FRAME of 10 days
B. Aspirin
HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG THEN Reduced to Low Dose Aspirin (3-5mg/kg/day) AND Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease)
SIMPLE FEBRILE SEIZURE vs. COMPLEX FEBRILE SEIZURE
Febrile Seizure: A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures
CLASSIFICATION BY CAUSE
A. Acute Symptomatic (shortly after an acute insult) Infection Hypoglycemia, low sodium, low calcium Head trauma Toxic ingestion
B. Remote Symptomatic Pre-existing brain abnormality or insult Brain injury (head trauma, low oxygen) Meningitis Stroke Tumor Developmental brain abnormality
C. Idiopathic No history of preceding insult Likely genetic component
SEIZURES
> Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons
> Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause
> Status epilepticus: >30min or back-to-back w/o return to baseline
> Etiology: - V ascular : AVM, stroke, hemorrhage - I nfections : meningitis, encephalitis - T raumatic : - A utoimmune : SLE, vasculitis, ADEM - M etabolic : electrolyte imbalance - I diopathic : idiopathic epilepsy - N eoplastic : space occupying lesion - S tructural : cortical malformation, prior stroke - S yndrome : genetic disorder
SIMPLE FEBRILE SEIZURE
A. Criteria for an SFS < 15 minutes Generalized-tonic-clonic Fever > 100.4 rectal to 101 F (38 to 38.4 C) No recurrence in 24 hours No post-ictal neuro abnormalities (e.g. Todds paresis) Most common 6 months to 5 years Normal development No CNS infection or prior afebrile seizures
B. Risk Factors Febrile seizure in 1 st / 2 nd degree relative Neonatal nursery stay of >30 days Developmental delay Height of temperature
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
BRONCHIAL ASTHMA (GINA GUIDELINES)
Controlled Partly Controlled Uncontrolled Day symptoms none > 2x per wk 3 or more symptoms of Partly Controlled Asthma in any week Limitation of activities none any Nocturnal Sx (awakening) none any Need for reliever < 2x per wk > 2x per wk Lung function normal < 80% Exacerbation none > 1x per yr 1x / week
TUBERCULOSIS
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
B. Extrapulmonary TB Same in PTB
For severe life threatening disease (e.g. miliary, meningitis, bone, etc)
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. Impaired/delayed surfactant synthesis & secretion 2. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance 3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis 5. Pulmonary vasoconstriction 6. Impaired endothelial &epithelial integrity 7. Proteinous exudates 8. RDS
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 0.02 ml/k IM, IV, ET Bicarbonate 1-2 meq/k Calcium 10 mg elem Ca/k slow IV Calcium chloride 0.33/k (27 mg Ca/cc) Calcium gluconate 1 cc/k (9 mg Ca/cc) Dextrose 1g/k = 2 cc/k D50 4 cc/k D25 Epinephrine 0.01 cc/k IV, ET
UMBILICAL CATHERIZATION
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
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
Clinical Features:
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
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
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
BILIRUBIN
PRETERM: mg/dl mmol/L 0-1 hr 1-6 17-100 1-2 d 6-8 100-140 3-5 d 10-12 170-200
TERM mg/dl mmol/L 0-1 hr 2-6 34-100 1-2 d 6-7 100-120 3-5 d 4-12 70-200 1 mo <1 <17
KRAMERS CLASSIFICATION OF JAUNDICE
ZONE JAUNDICE SERUM BILIRUBIN I Head & neck 6-8 II Upper trunk to umbilicus 9-12 III Lower trunk to thigh 12-16 IV Arms, legs, below 15 V Hands & feet 15
LUMBAR PUNCTURE
the technique of using a needle to withdraw cerebrospinal fluid (CSF) from the spinal canal.
SPINE spinal cord stops near L2 lower lumbar spine (usually between L3-L4 or L45) is preferable
CSF clear, watery liquid that protects the central nervous system from injury cushions the brain from the surrounding bone. It contains: glucose (sugar) protein white blood cells Rate : 500ml/day or 0.35ml/min Range : 0.3-04 ml/min Volume : 50ml (infants) 150ml (adults)
Indication to diagnose some malignancies (brain cancer and leukemia) to assess patients with certain psychiatric symptoms and conditions. for injecting chemotherapy directly into the CSF (intrathecal therapy)
To diagnose other medical conditions such as: viral and bacterial meningitis syphilis, a sexually transmitted disease bleeding around the brain and spinal cord multiple sclerosis, (affects the myelin coating of the nerve fibers of the brain and spinal cord) Guillain-Barr syndrome, (inflammation of the nerves)
Procedure Apply local anesthetic cream (ideally) Position the patient Prepare the skin using sterile techniques Anesthetize the area with lidocane Puncture the skin in the midline just caudal to the spinus process, angle cephalad toward the umbilicus using a g23 needle Collect the CSF for analysis
CSF Analysis 1. Gram stain, culture and sensitivity 2. Cell count, differential count 3. Chemistries sugar, protein 4. Special studies
After care Cover the puncture site with a sterile bandage, apply pressure packing. Patients must remain lying down for 4-6 hours NPO for 4 hrs