二階外科複習09: 小兒外科

資料來源：趙俊彥外科學

1. 小兒輸液

• 水分
• Infant: 100~120/kg/day (能量需求也差不多是這樣算-->大卡)
• >1 yrs: 100/50/20  rule
• 小朋友血量：85 x kg  c.c./  大人血量： 75 x kg c.c.
• 電解質
• 胞外：鈉氯鈣/  胞內：鉀磷鎂
• Na, Cl: 2 mEq/kg/day
• Ca, K, P: 1 mEq/kg/day
• Mg: 0.25 mEq/kg/day

2. Hypertrophic pyloric stenosis

• 男>女，先天性肥大，約3~6 wks old
• 成因：缺乏神經叢(alpha plexus)無法窄縮--> proximal part肥大
• 表現：無膽汁嘔吐，右上腹橄欖狀腫塊，代謝性鹼中毒(低血氯、重碳酸高)
• 影像：string sign，超音波則看到pylorus擴大(1.4cm)+muscle增厚(0.4cm)+括約肌長度增加
• 處置：非緊急手術(pyloromyotomy) 
• 預後：良好

3. Intussusception

• 好發於6個月到2歲(換副食品)、迴腸套住盲腸
• 風險因子：曾經病毒感染(大人：腫瘤如平滑肌瘤、adenocarcinoma)
• 症狀：陣發性(10~15mins)哭鬧、縮腿蜷曲、currant jelly stool(黏液性血便)、觸摸到腹部香腸狀腫塊
• 影像：contrast enema(兼具治療)--> coil spring sign
  
• 處置：NPO+ NG decompression+ IV+ antibiotics+ enema(90%成功率/10%復發率)，入院觀察24hrs，若失敗則開刀徒手復位

4. Hirschsprung disease 先天性巨腸症

• 好發：男>女(4:1)，直腸(10%)、直腸+sigmoid(75%)
• 病因：缺乏神經節(alpha plexus)、相關上游神經增生
• 臨床表現：delayed meconium passage(>48hrs)、腹脹
• 影像：enema-->transitional zone, bizarre contraction, retention of barium> 24~48hrs，不事先灌腸
• 黃金診斷：biopsy(缺乏plexus、acetylesterase↑)
• 處置：避免enterocolitis，需要decompression+ antibiotics，手術處理
• 非緊急手術：two steps (colostomy-> resection-> anastomosis) at 6~12 months(>10kg)
• Swenson
• Duhamel
• Soave
  

5. Anorectal atresia  or anal atresia

• 胚胎：cloacal membrane在7th week碰觸到perineal body，8th week時開口
• 好發：男>女
• 分類
• 高位：puborectalis以上-->anorectal atresia，容易併膀胱/陰道/尿道fistula
• 低位：puborectalis以下-->anal atresia= membranous type，容易併會陰部fistula(80~90%)
• 影像：up side down X ray--> invertogram 
• 處理
• <1cm--> perineal shift in anoplasty
• >1cm--> colostomy, 4~6 months later anoplasty, another 3 months later close colostomy
• 預後：愈高位愈容易incontinence，術後能自由排便70%，然而完全不會滲便只有40%
• 合併症：VACTERL
  

6. NEC

• 滿月內嬰兒最常見的腹部急症
• 好發於出生後10~30天、terminal ileum、ascending colon
• 風險因子：早產、周產壓力(Infection, Ischemia, Immune)
• 臨床表現：Bell stage
• stage I: n/v
• stage II: abdominal distention and tenderness
• stage III: peritonitis, severe metabolic acidosis, DIC, sepsis

• 影像：pneumatosis intestinalis(經典)、gas in portal vein、fixed dilated bowel、free air(perforated)
  
• 處置：NPO、NG decompression、fluid support、antibiotic、兩階段手術(if 48~72hr未改善)

• 預後：overall mortality 80%
• 併發症：stricture、short bowel

7. Meconium ileus

• 好發於terminal ileum
• 原因：過於黏稠的meconium
• 風險因子: cystic fibrosis(西方人較多)
• Cl test in sweat >60 mEq/L
• CFTR gene
• 臨床表徵：腹脹、腸阻塞、delayed meconium passage
• 影像：plain film看到GGO(meconium+gas)、enema看到microcolon
• DDx: Hirschsprung disease
• 處置：enema(80%成功率)，失敗則開刀注射acetylcysteine+milking腸子

8. Omphalocele vs. Gastroschisis 

• 發生率：omphalocele(F>M)> gastroschisis
• 裂口大小：omphalocele(4cm↑)> gastroschisis(3~5cm)
• 合併症：omphalocele(30~70%)> gastroschisis(<10%)
• 死亡率：omphalocele(10~30%)> gastroschisis(5~15%)
• 處置：通常需要呼吸器+PPN、人工膜覆蓋(腹裂)、階段性修補

9. Umbilical hernia

• 自行關閉的條件：2歲以前、1.5cm以下

10. Meckel's diverticulum

• 消化道最常見的異常
• 成因：卵黃管的留存，屬於true diverticulum(whole layer)
• 好發：antimesenteric side
• 臨床表現：rule of two (+M>F, 2:1)，出血(因為異味胃組織)>堵塞>diverticulitis
  
• 處置：有併發症再開刀(segmental resection+ end to end anastomosis)，如果摸到的appendix很厚、懷疑有異生組織可一起拿掉
• DDx
• 若通道表皮= umbilico-ileal fistula (有mucus discharge)
• 若近端盲端= umbilical sinus

11. Intestinal atresia

• 好發於十二指腸> 空腸> 迴腸> 結腸
• 分類
• 食道、十二指腸閉鎖(40%併其他異常)：true embryologic abnormality
• 其他腸道閉鎖：intrauterine mesenteric vascular (SMA) accident
• 臨床表現：羊水過多、嘔吐、腹脹
• 影像：double bubble sign
• 處置：手術bypass、
• 合併症：30%Down syndrome、20%congenital heart disease，其他腸道閉鎖無合併其他先天異常
• P.S. Down syndrome最常合併的先天異常是congenital heart disease

12. Esophageal atresia

• 分類(Type C最常見)
   
• 臨床症狀：羊水過多、第一次餵奶就吐奶、recurrent choking、腹脹
• 影像：plain film- GI gas↑
• 處置：俯臥、頭高、NG decompression、NPO、antibiotics、開刀
• 合併症：40%VACTERL

13. Diaphragm hernia

• 解剖複習

• 最好發於左後外方(Bochdalek hernia)，其次在胸骨下方(Morgagni hernia)，最後才是esophageal旁的hiatal hernia(大人常見)
  
• 臨床症狀：肺發育不全、cyanosis、縱膈腔右推、腹部塌陷(scaphoid/empty abdomen)
• 影像：bowel gas in chest
• 處置：NPO、fluid、NG decompression、高濃度呼吸支持(幾乎都需要插管、壓力不能高)
• 預後：mortality 50%(主因為肺部)

14. Choledochal cyst/ biliary atresia

• 好發：女>男(4:1)，東方人>西方人
• Types
• I: 85%
• V: intrahepatic duct cystic dilation= Calori disease
• 臨床症狀：黃疸、腹痛(膽管炎、胰臟炎)、腫塊
• 影像：sono+ CT( IHD 增生不會dilation), Tc99m
• DDx: 新生兒肝炎(pathology->giant cell, consider biopsy)
• 處置
• 60天以內，行total excision(Kasai's operation + reconstruction(Y loop)
• transplantation(contraindication:metastatic CA, cirrhosis Child B/C)
  
• 預後：差
• 葛西式10 year survival rate=53%
• 肝移植10 year survival rate=66.7%
• 是否有膽囊膽道炎是重要因子

15. Wilms' tumor(nephroblastoma)

• 惡性，經血液轉移到肺臟
• 成因：基因突變刪除(Chr. 11= WT-1, WT-2, tumor suppressor gene)
• 好發：peak 3 y/o (1~7 y/o)
• 臨床症狀：腫塊、腹痛
• 影像：sono, CT, pyelography
• 治療：手術、化療，III, IV期+ radiation
• 預後：佳(五到十年存活率: 80~90%)

16. Neuroblastoma(腎上腺髓質、交感神經節後)

• 惡性，經血液轉移到肺臟，屬於APUD（amine precursor uptake and decarboxylation）的一種
• 成因：基因突變(Chr. 2= ameC, oncogene)
• 好發：80%<4y/o, peak 2 y/o，腎上腺髓質、交感神經節(腹部脊椎旁>縱膈腔>頸部)
• 成人最常見腎上腺髓質腫瘤為pheochromocytoma(90%良性)，也是APUD tumor
• 臨床症狀：腫塊、catecholamine造成的高血壓
• 檢驗：代謝產物VMA, HMA
• 治療：手術、化療
• 預後：差，survival rate =30%

17. 小兒常見死因

• 創傷
• 癌症：leukemia> brain tumor> neuroblastoma

18. Hepatoblastoma

• 小兒最常見肝臟惡性腫瘤，HCC次之
• 好發：3 y/o 以下 (HCC: 10~15 y/o)
• 檢驗：tumor marker- alpha fetal protein
• 影像：sono, CT
• 治療：手術為主，化療有效(HCC: 相對無效)
• 預後：survival rate =70% (HCC: 25%)

19. Torticollis 斜頸症

• 成因：SCM纖維化
• 大人成因：spasm
• 風險因子：剖腹產，一個月內就會發現
• 臨床表現：患側頸部硬塊，頸彎向患側、頭朝健側
• 治療：復健2~5個月，超過一年未恢復可手術(myotomy劃開)
• 合併症：頸椎、胸椎scoliosis、臉部變形
• 
  

Reviews Before becoming PGY: Pediatrics (下篇)

Reviews Before becoming PGY: Pediatrics (下篇)

References:
=UpToDate
=Medscape
=OSCE 臨床技能測驗完全攻略

=北榮兒科臨床手冊(104/08修訂版)
 

1. 抽搐
-問診重點

• 發作前：是否哭泣用力？藥物？創傷？近期生病？站立過久？感覺前兆？頭痛頭暈想吐
• 發作時：單側/雙側？局部/全身？有規律？時間多久？眼口睜開？對聲音/疼痛有反應？
• 發作後：是否混亂無法聽指示？是否有持續的神經學症狀？
• 其他：心理狀態、家族史、發展史等

- 抽搐常見原因(依常見度遞減)

• 熱痙攣、癲癇
• 電解質不平衡、中樞神經感染
• 腦瘤、蜘蛛膜下腔出血

- 抽搐鑑別診斷工具

• 必做ABG
• CBC, Na, Ca, Glu, NH3
• CSF
• cultures
• 遺傳診斷、藥物調查(urine)
• EEG對探討病因沒有太大的幫助；影像(brain sono/CT/MRI)有助於局部抽搐的診斷

2. Febrile convulsion
- 定義：

• 6個月~5歲
• 燒到38度(發燒後第一天就抽筋)
• 排除CNS infection和metabolic abnormalities
• 之前不能有過non-febrile convulsion

- 分simple & complex：simple的是全身性<15 mins且一天只有一次，但1/3還會復發
- risk factors 包括家族史、孕中暴露到尼古丁、iron deficiency、atopic diseases
- 治療：BZD等藥物(risk > benefit)

3. 發燒+紅疹
-  原因/特色：

• adenovirus：咽部肺部、角膜結膜發炎、出血性膀胱炎
• Kawasaki：口手足、草莓舌 
• enterovirus：口手足、心肌炎、咽峽炎、腦膜炎、肢體麻痺
• measles：鼻炎、咳嗽、結膜炎，退掉後有色素沉澱/脫皮，嚴重者支氣管炎/肺炎/全腦炎
• scarlet fever(Streptococccus)
• Roseola  Infantum(HSV-6,7)：blanching、Nagayama spot(懸雍垂附近)，退掉後沒有色素沉澱/脫皮
• drug allergy
• UTI

4. Asthma in children
- Differential of chronic cough


Algorithm for evaluation of chronic cough in children
retrieved from UpToDate

 

Reviews Before becoming PGY: Pediatrics (中篇)

Reviews Before becoming PGY: Pediatrics (中篇)- 新生兒黃疸

References:
=UpToDate
=OSCE 臨床技能測驗完全攻略

=北榮兒科臨床手冊(104/08修訂版)
=Jackie Lou C. Acha "hyperbilirubinemia" retrieved from SlideShare

1. Neonatal jaundice

- 生理性黃疸的五個原因：血紅球較多/turnover rate較高、血紅素較脆弱、肝臟無法有效conjugate bilirubin、腸道菌無法有效將bilirubin轉化出urobilinogen/stercobilin甚至藉beta-glucuronidase反轉回unconjugated form
- 生理性黃疸的特色：

• 多落在Bhutani nomogram的40 percentile以下(low risk)
• 時間上出生後1~2週內消失/ 不會在剛出生24hrs之內出現
• 足月/早產兒都會有，但早產兒較慢達peak(一週)、peak較高(15 mg/dl)、機率較大(80%)
• 不需治療

- 病理性黃疸的原因：溶血、非溶血(血腫/polycythemia/腸肝循環↑/UGT1A1 defect/hypothyroidism/bilirubin排泄障礙)
-病理性黃疸的特色：

• 太早--->出生後24hrs內
• 太高--->bilirubin >95 percentile
• 太高--->direct bilirubin >1mg/dl (total<5), or >20%(total>5)
• 太快--->0.2mg/dl per hour, 5mg/dl per day
• 太久--->持續兩週(足月)/三週(早產)
• 須注意潛在疾病，高於25mg/dl 會有神經傷害 (甚至更低就會!)

- 病理性黃疸的急慢性變化

• 急性：ABE- 高頻哭聲、嗜睡、肌肉低張力--> 發燒、肌肉高張力--> 呼吸中止、難以餵食、角弓反張、癲癇、昏迷、虛弱顫抖哭
• 慢性：kernicterus-  基底核、腦幹受損，產生不自主運動、聽覺異常、向上注視異常、琺瑯質不全

- 病理性黃疸的治療：照光、blood exchange、補albumin、IVIG、ursodeoxycholic acid、metalloporphyrin?

- Breast feeding jaundice and breast milk jaundice

from SlideShare

breast feeding jaundice--> encourage intake
breast milk jaundice--> stop breast feeding for 2~3 days

# http://www.pathophys.org/neonatal-hyperbilirubinemia/neonataljaundice-approach/

Reviews Before becoming PGY: Pediatrics (上篇)

Reviews Before becoming PGY: Pediatrics (上篇)

References:
=UpToDate
=OSCE 臨床技能測驗完全攻略
=北榮兒科臨床手冊(104/08修訂版)
=衛福部疾管署官網

1.  Failure to thrive
- 在兒童(<2 歲)稱為生長遲滯
- 操作型定義是生長速度遲緩，且體重低於<2%生長曲線
- 必須排除基因問題、IUGR、早熟、constitutional growth delay(骨齡成熟較慢)
- 源於營養不足(包括攝取/消化/代謝/吸收降低、排除/需求增加)
- 在調查原因的過程中，可以先試著調整食物配方

2. Developmental delay/milestones
- 包括動作(粗/細)、認知、語言、行為、社會/情緒/心理層面
- 須排除視力、聽力問題- 發展里程碑：

• 五個月-->雙手可抓東西/放入嘴巴
• 六個月-->對人哭笑反應/手上東西可換手拿
• 十個月-->可不用協助而坐/可用指尖拿東西/發出無意義聲音
• 一歲-->可扶著東西走路/理解簡單指示
• 十八個月大-->疊三四個積木/不用協助而走路
• 兩歲-->可組成句子

3. Acute abdominal pain
- 先了解是持續性或陣發性
- 按年齡鑑別診斷

• 0~2歲：腸套疊/扭結、腸胃炎、闌尾炎、腹股溝疝氣、幽門狹窄等
• 3~6歲：額外考慮便秘、呼吸泌尿感染、腫瘤、創傷、膽道囊腫
• 更大的兒童：額外考慮潰瘍、AIR、婦科問題　

- 按機制思考鑑別診斷

• 臟器發炎(往往伴隨發燒)
• 消化道阻塞(間歇性絞痛/含膽汁嘔吐)
• 血管性(缺血壞死/腫瘤囊腫/過敏性紫斑症)
• 創傷等其他因素

4. 腸病毒
- 有很多subtypes，包括polio,  Coxsackie A(口手足), Coxsackie B(肋膜痛/心肌炎)等
- 糞口/飛沫傳染，感染後兩周內最容易傳染，經上呼吸道1~3 wks/糞便3~8 wks
- 表現有皮膚疹、腦膜炎、腦炎、眼部感染(結膜炎)、肋膜痛、心肌炎/心包膜炎、肺炎/支氣管炎等
- 腸病毒重症前兆(通常在發病後第三天，不會超過一個禮拜)，持續有

• 嗜睡、意識改變、活力不佳、無力
• 肌躍型抽搐(類似驚嚇，睡覺時較頻繁)
• 肢體麻痺
• 頸部僵硬、發燒
• 嘔吐
• 呼吸急促
• 心跳加快或心律不整

甚至有交感神經興奮的症狀
- 腸病毒重症住院indications

• <3 歲
• 發燒超過3天
• 3大警訊(嗜睡、肌躍型抽搐、嘔吐)
• 血糖>150mg/dl
• WBC>17500 cumm

- 若懷疑影響中樞神經，可給予

• IVIG
• Fluid challenge
• CSF檢驗
• EKG monitor

- 分四期：手口足病/疱疹性咽峽炎期--> 中樞神經發炎期(反而要限水，避免心臟負荷)-->自主神經失調期-->心臟衰竭期(考慮ECMO)

 

小兒科雜記Pediatrics topic 1: Unconjugated hyperbilirubinemia in the newborn

Unconjugated hyperbilirubinemia in the newborn

0. Metabolism process review
-- Heme-->[heme oxygenase]-->biliverdin-->[biliverdin reductase]-->bilirubin-->[UGT1A1]-->conjugated bilirubin-->[beta-glucuronidase]-->unconjugated bilirubin

1. Total bilirubin:
-- usually > 1mg/dL
               # hematocrit 50~60% (more RBC)
               # shorter life span of RBC (85 days)
               # deficient UGT1A1

               # increased enterohepatic circulation

-- can reach 10~14 mg/dL @ 3~5 days old (East-Asians) 
-- resolves within the first one to two weeks after birth
-- >25 mg/dL:  bilirubin-induced neurologic dysfunction (BIND)--> kernicterus


2. Neonatal hyperbilirubinemia (>35 wks)
-- check hour-specific Bhutani nomogram: >95th percentile
-- severe if
             # appear at first 24 hrs
             #  >95th percentile
             # 0.2 mg/dL ↑ per hour
             # after 2 weeks
             # conjugated >1 mg/dL or >20 percent

3. Breast milk jaundice
-- >5 mg/dL for several weeks (max. 12 wks)
-- etiology: some unknown factor in milk promoting enterohepatic circulation

4. Breast feeding failure jaundice
-- combined with low output (urine+stool), hypovolemia, weight loss

小兒科topic four: stroke at young age

Stroke at young age

1. Stroke at young age: <45 y/o

2. Stroke is divided into two categories:

--hemorrhagic 

--ischemic (80%)

Key point: Need more strict fluid control in hemorrhagic pts

                Rule out ICH before lysis

                Rule out complex migraine with hemiparesis (rare but possible!)

3. Initial assessment:

FAST : face, arm, speech, time

First 10 minutes

-- ABCDE O2, monitor, IV (just like what we usually do in the ER)

    As for monitors, we may find AF via ECG, and may find aortic dissection with stoke-         like symptoms via CXR.

    As for IV, we may draw blood to check CBC, coagulation(before lysis), Cr(before contrast medium used), electrolytes/cardiac enzyme/glucose for DDx of cause.

-- history

-- PE (neurologic examinations)

First 25 minutes

-- CT scan to differentiate between hemorrhagic and ischemic stroke

-- Check the NIHSS 

First 45 minutes

-- CT report read

 3 hours after onset

-- Thrombolysis IV (0.9mg/kg, max:90mg, 10% bolus over 1 min, rest over 1 h)

However, children under 18 are usually NOT commended to receive thrombolytic therapy.

@ward

--  check consciousness, bilateral pupils, hemorrhagic signs( even if originally ischemic)

-- recurrent stroke within 2~4 wks

-- pneumonia , UTI, DVT

-- check underlying cause of the stoke

-- MRI

-- may transfer to other wards after 3 days with stable conditions

4. Those who cannot receive tPA:

-- aspirin 325 mg STAT

5. Special factors contributing to stroke at young age

-- MELAS( mitochondria, encephalopathy, lactate acidosis, stroke)

-- protein S, protein C, antithrombin, homocysteine, moyamoya

-- virus induced vasculitis

-- AIR: lupus coagulants, ANA

-- sickle cell disease
-- patent foramen ovale
-- Fabry disease

6. Treatment after 24 hrs 

-- aspirin 100 mg QD

-- dipyrimadole 25 mg TID

-- clopidogrel if old-aged, 75 mg QD

7. BP control

-- 185/110 before lysis, 220/120 after treatment (use labetalo= TRANDATE if HTN)

8. Random talk: ICH common spots

-- putamen

-- cerebellum

-- thalamus

-- subcortical region

-- pons

小兒科topic three: SLE and children

SLE and children

The following notes are simplified for quick review. If there are mistakes, please comment and point out!

1. Initial presentation: 

-- adults: rash

-- children: arthritis, nephropathy, ITP, diarrhea, seizure, psychosis 

2. Diagnosis

-- by clinical presentation 

-- by lab data

***clinical presentation***

--Mucocutaneous: skin, mouth, nasopharynx

--Musculoskeletal: joint

--Heart/lung: serositis

--Kidney: proteinuria>500 mg/dl or 3+

--Neuro: seizure, psychosis

--GI

--Hema: hemolytic anemia, WBC<4000, lymphocyte<1500, plt<100000

--AIR

***lab data***

--ANA: for diagnosis, not for long-term F/U

--ds-DNA

For high risk pts:

--anti-Sm
--anti-SSA. anti-SSB, ribonucleoprotein(U1-RNP)

--antiphospolipid: anti-cardiolipin, lupus anticoagulant,  beta-2 glycoprotein antibody 

May be (+) for ANA(-):

--anti-Ro

--anti-La

Others:

--anti-histone

--mixed Coomb's test: coagulation↓--> antibody(+); coagulation normal --> coagulation factors deficiency

3. Pregnancy and SLE

-- The mother:

                        higher spontaneous abortion possibility, 

                        check antiphospolipid, 

                        cannot use Cellcept (MMF)

--The child:

                        check anti-SSA/SSB for SLE risk if the mother has SLE

                        may lead to permenant heart block

4. Biopsy's role: for prognosis, before taking aggressive treatments( If the damage has become irreversible, there's no much need for aggressive treatment. )

5. Lupus nephritis

6. Drugs for SLE

--HCQ(hydroxychloroquine): ex. Plaquenil, for flare up, arthritis

--Corticosteroids: low dose for arthritis, high dose for major diseases

-- MTX: for rash, arthritis

--Belimumab: for rash , arthritis

--CYC(cyclophosphamide): for severe nephritis(type 4),  CNS 

--MMF(Mycophenolate): for nephritis

--CsA(cyclosporine): for renal disease

--Rituximab: for refractory SLE, ITP, AIHA

--ACEI, NSAID

7. Prognosis :

--Worse if course beginning at youth

--Renal failure, infections are major causes of morbidity and mortality

小兒科day three雜記

Pediatrics 小兒科day three  notes

Now there are some young patients with CKD in our department...So review some Nephrology!

1. Causes of high anion gap acidosis?

MUD PILES

-- Methanol

-- Uremia

-- Diabetes ketoacidosis

-- Propylene glycol

-- Infection, INH ( isoniazide )

-- Lactate acidosis( ex. Metformin may induce this!)

-- Ethylene glycol , Ethanol( leading to lactate acidosis?)

-- Salicylates

For Chinese users, we can use this mnemonic: 甲醇乙醇丙二醇；尿素乳酸水楊酸；DM/Infection/INH另外記

2. Causes of decreased anion gap acidosis?

USED CARP; If you cannot remember all, just remember these two: 

-- GI loss of bicarbonate

-- RTA

3. After long-term dialysis

-- EPS=  encapsulating peritoneal sclerosis; irreversible and associated with poor outcome

4. After kidney transplantation

-- OPD F/U: creatinine, drug concentration, fever; DDx: infection or rejection

-- Final tool: biopsy

-- Rejection: B cell type -->  use plasmapheresis, Rituximab

                     T cell type --> use immunosuppresants

5. Continue with previous notes on UTI

-- HPF: 6~10 WBC↑, suspect UTI

-- if orange urine--> more likely to be crystals instead of blood

-- Infection--> pyuria, not just bacteria in the urine

-- APN may last a few days without response to antibiotics.

6. Hemophagocytic syndrome (HLH)

-- Pancytopenia in the blood, Histiocytosis in the bone marrow

-- Fever

7. Pediatric IDA

-- Around 1 y/o, High Hgb is common in normal newborns (15~16 mg/dl)

-- Breast feeding: potential iron insufficiency

小兒科topic two: Abusive head trauma (AHT)

 Abusive head trauma (AHT)

1. Used to be called "shaken baby syndrome"

-- 80% due to physical abuse, therefore changed the name to AHT

-- Not likely to result from mild shakes or falling down from a short table by himself/herself

2. Patients: usually < 1 y/o, being abused many times

3. Prognosis: mortality 13~30%, handicapped 50~70%

4. Warning signs: 

-- Parents giving confusing information; especially young parents with financial stress

-- Burns, wounds (30~70%)

-- Seizure (40~70%)

-- Retinal hemorrhage (65~95%)

5. DDx:

-- Infection

-- Coagulopathy

-- Congenital defects

-- Accidental SDH (seizure/retinal hemorrhage-->uncommon, skull fracture-->more common)

6. Treatment:

-- Educate the parents

-- Drain CSF if high intracranial pressure (not doing this to remove blood clots!); 

   use EVD (external ventricular drainage) 

   or ETV (endoscopic third ventriculostomy) 

   or S-P shunt

7. High intracranial pressure: Cushing triad

-- Hypertension

-- Bradycardia

-- Irregular breathing

For babies, we can evaluate the anterior fontanelle to see if there's bulging due to high intracranial pressure.

8. CSF review:

-- Production: Choroid plexus in lateral ventricle 90%, 3rd and 4th ventricle 5%

-- Reabsorption: Luschka foramen *2, Magendie foramen*1

Amount: total 600~700 ml per day

Pressure: 9~18 mmH2O

Passage: Monro's foramen, Aqueduct 

小兒科day two雜記

Pediatrics 小兒科day two雜記

1. Ｈow to estimate the target height of a kid?

boy: (father's height+mother's height +12)/2 
girl: (father's height+mother's height -12)/2 

2. Precocious puberty for Caucasians

boy: <9, testis, pubic hair

girl: <8, breast, MC, pubic hair

pubic hair growth: pubarche

breast budding: thelarche

Tanner score

 

3. Pediatric asthma attack

-- IM epinepherine

-- IV hydrocortisol

-- Inhale Ventolin (fast!)

4. VACTERL 

Vertebral defects

Anal atresia

Cardiac defects

Tracheo-esophageal fistula

Renal anomalies

Limb abnormalities

5. Causes of conscious change

A-- Alcohol, anemia
E-- Electrolyte imbalance
I--  Insulin
O-- Opiates, oxygen
U-- Uremia

T-- Trauma, temperature, tumor
I--  Infection, inflammation
P-- Psychogenic
S-- Seizure, stroke

When applied on kids, mind trauma and encephalopathy(ex. anti-NMDA receptor encephalitis) 

5. Ｃatatonia: Over 3 points(+) among 12 symptoms

Symptoms--
Catalepsy, Waxy flexibility, Stupor, Agitation, Mutism, Negativism, Posturing, Mannerism, Stereotypes, Grimace, Echolalia, Echopraxia

Treatment--
BZDs

6. CKD complications

-- anemia

-- secondary hyperparathyroidism

-- shorter stature and lagging development

7. Post-transplantation(kidney) graft dysfunction

-- within 1 wk (after transplantation): rejection
-- within 1~12 wks :                            drug-related= CIN(ex. Tacrolimus)
-- within 3 months:                             chronic change, unknown causes

8. RTA (acidosis without gap)

--type 1: distal tubules, low K+, FeHCO3- <3. calcinosis; ex. Fanconi's syndrome, SSr, RA, SLE

--type 2: proximal tubules, low K+, FeHCO3- >15; ex. SLE, MM, WM

--type 4: RAS system down, high K+, FeHCO3- <3; ex. DM

9. JOUBURT syndrome

--  absence or underdevelopment of the cerebellar vermis

10. Febrile convulsion

-- More commin during 6 months ~ 5 y/o

-- Fever, generalized/symmetrical seizure; may use antipyretic when >38‘C

-- Symptoms relieved after several minutes (shorter than real seizures)

-- Do not have frequent recurrent episodes

-- DDx: seizure, trauma-induced, brain lesions, meningitis

11. Acytelcysteine indications

--  CIAKI : 1200mg BID (doubled!)

--  Expectorants

--  NAC intoxication

12. Trental (Pentoxyfylline) indications

--  PAOD

--  DM nephropathy

--  AIH???

13. Advanced glycation end-product

--proteins or lipids that become glycated as a result of exposure to sugars

14. Trenckhoff tube: two cuffs, for PPD

15. ESRD common causes in children

--  congenital defects 

--  UVR

--  GN( FSGN)

Relative rare causes: chemotherapy( cisplatin ), SLE

小兒科topic one: AKI

Topic One: 小兒AKI

1. AKI 的症狀：寡尿、甚至無尿，frequency/urgency等等

2. 尿量評估：

大人尿量正常值-- 2~4 ml/kg/hr

***Oliguria***

-- less than 1 mL/kg/h in infants
-- less than 0.5 mL/kg/h in children
-- less than 400 mL daily in adults

建議可每八小時重新評估一次

3. 其他I/O評估：

***自然逸散***

量= BSAx(300)~BSAx(500)的區間

一般人應該要有positive I/O！另外小兒限水時就控制在Intake= UOP+逸散量

***小兒身體水分多寡/腎臟功能初步評估***

- skin turgor (是否乾皺或水腫)
- anterior fontanelle (是否凹陷)
- anemia

- intake/urine output
- BW
- BUN, Cr

4. AKI的定義：

***RIFLE criteria***

R: Risk, GRF up to 25% reduction  or Urine output<0.5 ml/kg/hr for >8hrs

I:  Injury, GRF up to 50% reduction  or Urine output<0.5 ml/kg/hr for >16hrs

F: Failure, GRF up to 75% reduction  or Urine output<0.3 ml/kg/hr for >24hrs

L: Loss, >4 wks

E: End-stage, >3 months

RIFLE criteria

4. 小兒AKI 的原因

***Pre-renal***(最常見)

-- dehydration

-- hypoalbuminemia

-- sepsis

-- hemorrhage

-- heart failure

***Renal***(在台灣很罕見)

-- Hemolyric uremic syndrome

 (http://emedicine.medscape.com/article/201181-overview)

***Post-renal***(通常是先天異常)

-- UPJ

-- UVJ (posterior, female)

5. 小兒AKI處置

-- 利尿劑
-- bicarbonate( if acidosis)
-- Keep electrolyte balance: treat hyperpotassemia(正常值3.5~4.7) by Kalimate/furosemide?/beta agonist/insulin/bicarbonate/calcium gluconate 
-- 透析 (if severe hyperpotassemia、intoxication,、或許conscious change也算)

6. 各種選擇透析的時機?(暫時跳脫出來聊一下)

***嚴重難控制的AEIOU***

A: Acidosis
E: Electrolyte imbalance
I: Intoxication
O: Overloaded fluid
U: Uremia

腎功能也是評估要點，如CCR計算、GFR計算

***Schwartz equation***

CCR or GFR =k* L(身長, cm)/Pcr (血中creatinine)
k = 0.45 for infants 1 to 52 weeks old
k = 0.55 for children 1 to 13 years old
k = 0.55 for adolescent females 13-18 years old
k = 0.7 for adolescent males 13-18 years old

CCR= urine Cr * 24 hr UOP* 1.733/(serum Cr * 1440* BSA) 二十四小時urine較難留！

CCR= 1, normal
CCR= 2, 50%↓
CCR= 4, 70~75%↓
CCR= 8, 90~95%↓

對照正常值

7.  小兒AKI情況下選擇透析模式?
透析分兩種，一種腹膜、一種血液，血液又分長時間(連續性的)和較短期的
- PPD: 小兒最常用，因為血液量太少，血液透析造成的不穩定性太高
- hemofiltration:沒加透析液，靠水壓透析，較適用於hemodynamic不穩的病人
- hemodialysis: 有加透析液，靠滲透壓透析
- CVVH: 洗的速率較慢，病人比較被束縛，容易鉀、磷低下，可以順便洗掉cytokine
- CVAH

8. CVVH液分析
-- A液:  CVVH solution(含電解質)
-- B液: half saline+  sodium bicarbonate(所以可以洗CVVH解決acidosis！)

9. 透析的副作用/終點
-- 洗的過程中所有lab數據都會變漂亮(受控制中)，所以無法藉由lab評估是否停止透析
-- 主要還是評估尿量
-- 副作用包括：頭暈不適、血壓不穩、管路clot/感染、低鉀低磷、高血鈉

小兒科day one雜記

小兒科day one 雜記

小兒科的CXR判讀

A-- Airway
B-- Bone
C-- Cardiac( heart )
D-- Diaphragm( air? effusion?)
E-- Equilibrium( lung field )

Bacterial infection vs. Viral infection in URI

要怎麼區分這兩者呢？
首先，症狀上，細菌感染的寶寶比較不清醒、活動力較低、食慾不佳吃少少的，口訣就是3A降低(和棒球沒關係XD)，也就是學長姐口中的「病人症狀比較toxic」：

Appearance/Alertness
Activity
Appetite

病毒性感染則較容易 n/v, diarrhea

再來，看X光片也能區分，細菌性感染比較會出現patchy lesions，pleural effusion較明顯；相對的病毒性感染，會出現廣泛性的infiltration

最後，atypical infection容易合併肺外症狀，例如小兒常見的Mycoplasma(ESR↑CRP↑, CBC→, cold coagulation(+)西瓜沙貌)

URI vs. LRI

LRI-- 3A降低的症狀更明顯、病程超過1週、cyanosis、subcostal retraction

Streptococcus infection

診斷

1.  沒有cough, rhinorrhea

2.  Tonsil, anterior LN腫大    (compare: EBV造成posterior cervical LN 腫大）

3.  Strep. quick test(+)

後遺症

1. Scarlet fever(初次感染)/ Rheumatic fever(Type 2自體免疫)

2. PSGN

Febrile convulsion

1. 通常在發病初期就出現

2. 病人往往 < 5 y/o

3. 肇因：Roseola, Shigella...

4. 必要時可作lumbar puncture-- DDx: meningitis

 DDx: myoclonic jerk in 腸病毒重症

Catecholamine storm

1. 血壓、心跳、血糖↑

2.甚至最後可能需要on ECMO

3. 可能出現在腸病毒重症的患者身上

UTI 

1. 症狀不一定能從病人本身問到、得知

2. 通常是fever之後再去查各種感染源

3. 若常常recurrent or有 hydronephrosis要懷疑先天結構異常

診斷

1. Urine routine: 

***Nitrate may be an indication of UTI***

2. 腹部超音波

DDx:阻塞?

3. DMSA 腎臟掃描

4. VCUG 後續檢察

DDx: VUR? (必要時給prophylatic antibiotics, 內視鏡治療)