Professional Documents
Culture Documents
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
EXPECTED LA SALLIAN
GRADUATE ATTRIBUTES
(ELGA)
Up to 6 mo: 1 half tab per day for 10-14 days ◦ reassess after 6 hrs (infant) & 3 hrs (child)
6 months or more: 1 tab or 20mg
OD x 10-14 days
3. Continue feeding
4. Know when to return
TREATMENT PLAN B
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
ORS
• Glucolyte 60 • Pedialyte 45 0r 90
ETIOLOGY OF PNEUMONIA
Bacterial
- Streptococcus pneumoniae
- Group B streptococci (neonates)
ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)
- 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 (Croup)
- Influenza types A, B
- Adenovirus
- Metapneumovirus
Fungal
- Histoplasma capsulatum (bird, bat contact)
- Cryptococcus neoformans (bird contact)
Child Age 2months up to 5years
- Mucormycosis (immunosuppressed)
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii (immunosuppressed,
HIV, steroids)
SMR GIRLS
LUDAN’S METHOD (HYDRATION THERAPY) Stage Pubic Hair Breasts
1 Preadolescent Preadolescent
MILD MODERATE SEVERE Sparse, lightly pigmented, straight, Breast & papilla elevated, as small
DEHYDRATION DEHYRATION DEHYDRATION 2
medial border of labia mound, areola diameter increased
< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg Breast & areola enlarged, no contour
3 Darker, beginning to curl, ▲amount
> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg separation
D5 0.3% in 1st hr: ¼ Plain LR 1st hr: ⅓ Plain LR 4
Course, curly, abundant but amount < Areola & papilla formed secondary
6-8 hours Next 5-7 hrs: Next 5-7 hrs: adult mound
¾ D5 0.3% in ⅔ D5 0.3% in Adult, feminine triangle, spread to Mature, nipple projects, areola part of
5
5-7 hours 5-7 hours medial surface of thigh general breast contour
DENGUE PATHOPHYSIOLOGY
> Neonates (<1mo) - RSV
- GBS - Other respiratory viruses
- E. coli - Streptococcus pneumoniae
- other gram (-) bacilli - Haemophilus influenzae (Type B)
- Streptococcus pneumoniae - C. trachomatis
- Haemophilus influenza (Type B) - M. pneumoniae
- Group A Streptococcus
> 1-3 months - Staph aureus
* Febrile pneumonia
- RSV > 2-5 yrs
- Other respiratory viruses - Streptococcus pneumoniae
- Streptococcus pneumoniae - Haemophilus influenzae (Type B)
- Haemophilus influenza (Type B) - C. trachomatis
- M. pneumoniae
* Afebrile pneumonia - Group A Streptococcus
- Chlamydia trachomatis - Staph aureus
- Mycoplasma homilis
- CMV
> MOT: mosquito bite (man as reservior) Biphasic fever (2-7 days) with 2 or more of the ff: Manifestations of DHF plus signs of circulatory failure
1. rapid & weak pulse
> Vector: Aedes aegypti 1. headache 2. narrow pulse pressure (<20mmHg)
2. myalgia or arthralgia 3. hypotension for age
> Factors affecting transmission: 3. retroorbital pain 4. cold, clammy skin & irritability / restlessness
- breeding sites, high human population density, 4. hemorrhagic manifestations
mobile viremic human beings [petechiae, purpura, (+) torniquet test]
5. leukopenia DANGER SIGNS OF DHF
> Age incidence peaks at 4-6 yrs
1. abdominal pain (intense & sustained)
> Incubation period: 4-6 days Dengue Hemorrhagic Fever (DHF) 2. persistent vomiting
3. abrupt change from fever to hypothermia
> Serotypes: 1. fever, persistently high grade (2-7 days) with sweating
- Type 2 – most common 2. hemorrhagic manifestations 4. restlessness or somnolence
- Types 1& 3 - (+) torniquet test
- Type 4– least common but most severe - petechiae, ecchymoses, purpura
- bleeding from mucusa, GIT, puncture sites Grading of Dengue Hemorrhagic Fever
> Main pathophysiologic changes: - melena, hematemesis
a. increase in vascular permeability 3. Thrombocytopenia (< 100,000/mm3)
▼ 4. Hemoconcentration
extravasation of plasma - hematocrit >40% or rise of >20% from baseline
- hemoconcentration - a drop in >20% Hct (from baseline) following
- 3rd spacing of fluids volume replacement
- signs of plasma leakage
b. abnormal hemostasis [pleural effusion, ascites, hypoproteinemia]
- vasculopathy
- thrombocytopenia
- coagulopathy
> Hyperkalemia may be seen due to Na+ retention - 10 days of Oral Penicillin or Erythromycin
> Ca++ decreases in PSAGN - IM Injection of Benzethine Penicillin
> ▲ in ASO titer
- normal within 2 weeks
- peaks after 2 weeks
- more pronounced in pharyngeal infection
than in cutaneous
B. Secondary Prevention
C. Duration of Chemoprophylaxis
KAWASAKI DISEASE
TREATMENT SEIZURES
CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI Currently Recommended Protocol:
(ALL SHOULD BE PRESENT) > Seizures: sudden event caused by abrupt,
A. IV-Immunoglobulin uncontrolled, hypersynchronous
A) HIGH Grade Fever (>38.5 Rectally) PRESENT discharges of neurons
for AT LEAST 5-days without other Explanation 2g/kg Regimen Infusion EQUALLY Effective in
“High Grade Fever of at least 5 days” Prevention of Aneurysms and Superior to 4-day > Epilepsy: tendency for recurrent seizures that are
DOES NOT Respond to any kind of Antibiotic! Regimen with respect to Amelioration of Inflammation unprovoked by an immediate cause
as measured by days of
B) Presence of 4 of the 5 Criteria Fever, ESR, CRP, Platelet Count, Hgb, and Albumin > Status epilepticus: >30min or back-to-back
1. Bilateral CONGESTION of the Ocular Conjunctiva w/o return to baseline
(seen in 94%) NOTE: There is a TIME FRAME of 10 days
2. Changes of the Lips and Oral Cavity (At least ONE) > Etiology:
3. Changes of the Extremities (At least ONE) - V ascular : AVM, stroke, hemorrhage
4. Polymorphous Exanthem (92%) B. Aspirin - I nfections : meningitis, encephalitis
5. Cervical Adenopathy = Non-Suppurative Cervical - T raumatic :
Adenopathy (should be >1.5cm) in 42%) HIGH Dose ASA (80-100mg/kg/day divided q 6h) - A utoimmune : SLE, vasculitis, ADEM
should be given Initially in Conjunction with IV-IG - M etabolic : electrolyte imbalance
HARADA Criteria THEN - I diopathic : “idiopathic epilepsy”
- used to determine whether IVIg should be given Reduced to Low Dose Aspirin (3-5mg/kg/day) - N eoplastic : space occupying lesion
- assessed within 9 days from onset of illness AND - S tructural : cortical malformation,
1. WBC > 12,000 Continued until Cardiac Evaluation COMPLETED prior stroke
2. PC <350,000 (approximately 1-2 months AFTER Onset of Disease) - S yndrome : genetic disorder
3. CRP > 3+
4. Hct <35%
5. Albumin <3.5 g/dL
6. Age 12 months
7. Gender: male
UMBILICAL CATHERIZATION
NEWBORN RESUSCITATION Cathether length
Indications • Standardize Graph
AIRWAY: open & clear • Vascular access (UV) – Perpedicular line from the tip of the shoulder to
• Positioning • Blood Pressure (UA) and blood gas monitoring in the umbilicus
• Suctioning critically ill infants • Measure length from Xiphoid to umbilicus and add
• Endotracheal intubation (if necessary) 0.5 to 1cm.
Complications • Birth weight regression formula
BREATHING is spontaneous or assisted • Infection – Low line : UA catheter in cm = BW + 7
• Tactile stimulation (drying, rubbing) • Bleeding – High line : UA catheter = [3xBW] + 9
• Positive-pressure ventilation • Hemorrhage – UV catheter length = [0.5xhigh line] + 1
• Perforation of vessel
CIRCULATION of oxygenated blood is adequate • Thrombosis w/ distal embolization Procedure
• Chest compressions • Ischemia or infarction of lower extremities, bowel or • Determine the length of the catheter
• Medication and volume expansion kidney • Restrain infant and prep the area using sterile
• Arrhythmia technique
• Air embolus • Flush catheter with sterile saline solution
• Place umbilical tape around the cord. Cut cord
RESUSCITAION MEDICATIONS Cautions about 1.5-2cm from the skin.
• Never for: • Identify the blood vessels.
– Omphalitis (1thin=vein, 2thick=artery)
Atropine 0.02 ml/k IM, IV, ET
– Peritonitis • Grasp the catheter 1cm from the tip. Insert into the
Bicarbonate 1-2 meq/k • Contraindicated in vein, aiming toward the feet.
10 mg elem Ca/k slow – NEC • Secure the catheter
Calcium
IV – Intestinal hypoperfusion • Observe for possible complications
Calcium chloride 0.33/k (27 mg Ca/cc)
Calcium gluconate 1 cc/k (9 mg Ca/cc) Line Placement
Dextrose
1g/k = 2 cc/k D50 • Arterial line
4 cc/k D25 • Low line
Epinephrine 0.01 cc/k IV, ET – Tip lie above the bifurcation between L3 & L5
• High line
– Tip is above the diaphram between T6 & T9
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
SERUM
ZONE JAUNDICE
BILIRUBIN
I Head & neck 6-8
Upper trunk
II 9-12
to umbilicus
Lower trunk
III 12-16
to thigh
Arms, legs,
IV 15
below
V Hands & feet 15
MKD COMPUTATION
LUMBAR PUNCTURE • To diagnose other medical conditions such as:
– viral and bacterial meningitis Wt x mkd x preparation [mg/mL] = mL per dose
• the technique of using a needle to withdraw – syphilis, a sexually transmitted disease
cerebrospinal fluid (CSF) from the spinal canal. – bleeding around the brain and spinal cord e.g. 12kg x 10mg x 5ml = 5mL per dose
– multiple sclerosis, (affects the myelin coating of 120mg
SPINE the nerve fibers of the brain and spinal cord)
• spinal cord stops near L2 – Guillain-Barré syndrome, (inflammation of the * If per day, divide total (mL) by the # of divided doses
• lower lumbar spine (usually between L3-L4 or nerves)
L4–5) is preferable Dose x preparation x frequency = mkd
Complication weight
CSF • Local pain
• clear, watery liquid that protects the central nervous • Infection
system from injury • Bleeding Paracetamol Drops = Wt: move 1 decimal
• cushions the brain from the surrounding bone. • Spinal fluid leak point to the left
• It contains: • Hematoma (spinal subdural hematoma Age Wt
– glucose (sugar) • Spinal headache 1 10 kg
– protein • Acquired epidermal spinal cord tumor 2 12
– white blood cells 3 14
• Rate : 500ml/day or 0.35ml/min Caution & Contraindications 4 16
• Range : 0.3-04 ml/min • Increased ICP 5 18
• Volume : 50ml (infants) • Bleeding diasthesis 6 20
150ml (adults) • Traumatic Tap
• Overlying skin infection 1 drop = 1/20 mL
Indication • Unstable patient 1 teaspoonful = 5 mL
• to diagnose some malignancies (brain cancer and 1 tablespoonful = 15 mL
leukemia) 1 wineglassful = 60 mL = 2 ounces
• to assess patients with certain psychiatric 1 glassful = 250 mL = 8 ounces
symptoms and conditions. 1 grain = 60 mg
• for injecting chemotherapy directly into the CSF 1 pint = 500 mL
(intrathecal therapy) 1 quart = 1000 mL
1 ounce = 30 mL
1 Kg = 2.2 lbs
1 lb = 0.45359 Kg
Empirical dose
➢ 6 months ¼ tsp TID QID
Procedure ➢ 6 mos – 2 yrs ½ tsp
• Apply local anesthetic cream (ideally) ➢ 2-6 1 tsp
• Position the patient ➢ 6-9 1 ½ tsp
• Prepare the skin using sterile techniques ➢ 9-12 2 tsp
• 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
CLINICAL FEATURES
CLASSIFICATION BASED ON SEVERITY
RESPIRATORY
MILD MODERATE SEVERE
ARREST
PERSISTENT - talking
INTERMITTENT
MILD MODERATE SEVERE - INF: softer, - at rest
Affects shorter, cry, - INF: stops
Affects daily Limits daily - walking
daily Breathless difficulty feeding Imminent
Exacerbation Brief activity & activity & - can lie down
activity & feeding - hunched
sleep sleep - prefers forward
sleep
Day-time Sxs <1x/wk >1x/wk daily continuous sitting
Nightime Sxs <2x/mo >2x/mo >1x/wk frequent Talks in sentences phrases words
PEFR >80% >80% 60 - <80% <60% may be usually usually drowsy /
Alertness
PEFR VAR <20% 20 - 30% >30% >30% agitated agitated agitated confused
FEV1 >80% >80% 60 - <80% <60% often >30
RR ▲ ▲ bradypnea
mins
Accessory
(+) thoracoabd
muscles & none (+) (+)
movement
retractions