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

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

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

Centimeters
50
75
Age x 6 + 77

Age
Inches
20
30
Age x 2.5 + 30

At Birth
1y
6y

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

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

FONTANELS

st

Gain in 1 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

Appropriate size at birth:

Closes at:
Anterior

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)

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

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

(-)
Response

Grimaces

(-)
Movement

Some flexion /
extension

Absent

Slow / Irregular

transverse chest diameter

AP diameter

Function
Eye
Opening

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

: 1.0
: 1.25
: 1.35

#
1

ROUTE
ID

SITE
RDeltoid

IM

Upper
Outer
thigh
Mouth
Anterolateral
thigh
Outer
upper
arm
LDeltoid
Deltoid

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

GCS

Motor

EXPANDED PROGRAM ON IMMUNIZATION

VACCINE
BCG-1

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)
Age
At Birth
< 4 mo

Transverse-AP
Diameter ratio
1.0
1.25
1.35

0
Blue /
Pale
Absent

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

4 wks
4 wks
4 wks

1 mo then
6-12 mos

OPV
HEPA B
MEASLES

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
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

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?
F.R.I.C.H.M.O.N.D.

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

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

DIARRHEA

ACUTE DIARRHEA (at least 3x BM in 24 hrs)

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

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)

For severe dehydration / WHO hydration

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

30mL/kg
1H
30 mins

75mL/kg
5H
2H

Ingestion of rotavirus rotavirus in intestinal villi

destruction of villi
(secretory diarrhea absorption secretion) AGE
Assessment of dehydration (Skin Pinch Test)

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

(+) if > 2 seconds

no dehydration if skin tenting goes back
immediately

ETIOLOGY of AGE
Bacteria
Aeromonas
Bacillus cereus
Campylobacter jejuni
Clostridium perfringens
Clostridium difficile
Escherichia coli
Plesiomonas shigelbides
Salmonella
Shigella
Staphylococcus aureus
Vibrio cholerae 01 & 0139
Vibrio parahaemolyticus
Yersinia enterocolitica

Viruses
Astroviruses
Caloviruses
Norovirus
Enteric Adenovirus
Rotavirus
Cytomegalovirus
Herpes simplex virus

Parasites
Balantidium coli
Blastocyctis hominis
Cryptosporidium
Giardia lamblia
Amoeba
Ascariasis
Cholera
Shigella
Salmonella

TREATMENT PLAN A

Metronidazole
Al/mebendazole
Tetracyline
TMP/SMX (Cotri)
Chloramphenicol

TREATMENT PLAN C

4 Rules of Home Treatment

Treat severe dehydration QUICKLY!

1. Give extra fluid (as much as the child will take)

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

> 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

Infants
(<12mo)
Children
(12mo-5yrs)

How much fluid to be given in addition to the usual

fluid intake?
Up to 2 years:

First give
30mL/kg in:

Age

50-100 mL after each

loose stool

Then give
70mL/kg in:

1 hour*

5 hours

30 min*

2 hours

Repeat once if radial pulse is very weak or not

detectable

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

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)

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 B
Recommended amount of ORS over 4 hour period
Age up to:
Wt:
(mL)

4 mo 4 mo
<6kg
200-400

12 mo 12 mo
6-9.9kg
400-700

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

2 yrs 2 yrs
10-11.9kg
700-900

5 yrs
2-19kg
900-1400

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

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

Glucose 45mEq
Na: 20mEq
K: 35mEq
Citrate: 30mEq
Dextrose: 20g

Gluconate:
5mmol/L

Hydrite
-: 2 tab in 200ml water or 10sachets in 1L water
Glucose:
111mmol/L
Na:
90 mmol/L
K:
20 mmol/L

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

Pedialyte 45 0r 90
-: prevention of DHN & to maintain normal
fluidelectrolyte balance in mild to moderate
dehydration.
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:
11mml/L
Na:
90 mmol/L
K:
20 mmol/L

Glucose: 30mEq
Na: 20mEq
K:
30mEq

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

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.

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

ORS

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
- Aspergillus sp.
- Mucormycosis
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii

Young Infants < 2months old

ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)

ETIOLOGY OF PNEUMONIA

Child Age 2months up to 5years

(Croup)

(bird, bat contact)

(bird contact)
(immunosuppressed)
(immunosuppressed)
(immunosuppressed,
HIV, steroids)

SMR GIRLS
LUDANS METHOD (HYDRATION THERAPY)

< 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

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

HOLIDAY-SEGAR METHOD (MAINTENANCE)

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

Stage
1
2
3
4
5

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

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
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

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

ATYPICAL PNEUMONIA
-:
-:
-:
-:
-:

> 3-12 mo
- RSV
- Other respiratory viruses
- Streptococcus pneumoniae
- Haemophilus influenzae (Type B)
- C. trachomatis
- M. pneumoniae
- Group A Streptococcus

extrpulmonary manifestations
low grade fever
patchy diffuse infiltrates
poor response to Penicillin
negative sputum gram stain
Etiologic Agents Grouped by Age

> Neonates (<1mo)

- GBS
- E. coli
- other gram (-) bacilli
- Streptococcus pneumoniae
- Haemophilus influenza (Type B)
> 1-3 months
* Febrile pneumonia
- RSV
- Other respiratory viruses
- Streptococcus pneumoniae
- Haemophilus influenza (Type B)
* Afebrile pneumonia
- Chlamydia trachomatis
- Mycoplasma homilis
- CMV

DENGUE
> MOT:

mosquito bite

> Vector:

Aedes aegypti

> 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 Fever Syndrome (DFS)

(man as reservior)

> Factors affecting transmission:

- breeding sites, high human population density,
mobile viremic human beings

Biphasic fever (2-7 days) with 2 or more of the ff:

1. headache
2. myalgia or arthralgia
3. retroorbital pain
4. hemorrhagic manifestations
[petechiae, purpura, (+) torniquet test]
5. leukopenia

DENGUE PATHOPHYSIOLOGY

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

> 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
rd
- 3 spacing of fluids
b. abnormal hemostasis
- vasculopathy
- thrombocytopenia
- coagulopathy

MANAGEMENT OF DENGUE
A. Vital Signs and Laboratory Monitoring
Monitor BP, Pulse Rate
We have to watch out for Shock (Hypotension)

Dengue Hemorrhagic Fever (DHF)

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
3. Thrombocytopenia (< 100,000/mm )
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]

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 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

URINARY TRACT INFECTION

Suggestive UTI:
3
- Pyuria:
WBC 5/HPF or 10mm
- 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

> if PT & PTT are abnormal: FFP

> if PTT only: cryprecipitate
st

3-7cc/kg/hr depending on the Hct (1 no.) level

(D5LR)
10-20cc/kg fast drip PLR - hypotension, narrow pulse
pressure fair pulse
Leukopenia in dengue:
therefore:

probable etiology is
Pseudomonas

give Meropenem or Ceftazidime

ACUTE GLOMERULONEPHRITIS
Complications of AGN
- CHF 2 to fluid overload
- HPN encephalopathy
- ARF due to GFR

RHEUMATIC FEVER

TREATMENT OF RHEUMATIC FEVER

JONES CRITERIA:

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
- Proteinuria
- C3
- microscopic hematuria

2-3 weeks
3-6 weeks
8-12 weeks
6-12 mo or
1-2 years
4-6 weeks

- HPN

A. Major Manifestations
- Carditis
- Polyarthritis
- Chorea
- Erythema Marginatum
- Subcutaneous Nodules

A. Antibiotic Therapy
- 10 days of Oral Penicillin or Erythromycin
- IM Injection of Benzethine Penicillin
(50-60%)
(70%)
(15-20%)
(3%)
(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

*** 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

> 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

B. Secondary Prevention

C. Duration of Chemoprophylaxis

- 10 days of Oral Penicillin or Erythromycin

- IM Injection of Benzethine Penicillin

KAWASAKI DISEASE
TREATMENT
CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI
(ALL SHOULD BE PRESENT)

Currently Recommended Protocol:

A. IV-Immunoglobulin

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!

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

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%)

NOTE:

> 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

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)

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

SEIZURES

> Etiology:
- V ascular
- I nfections
- T raumatic
- A utoimmune
- M etabolic
- I diopathic
- N eoplastic
- S tructural

:
:
:
:
:
:
:
:

- S yndrome

AVM, stroke, hemorrhage

meningitis, encephalitis
SLE, vasculitis, ADEM
electrolyte imbalance
idiopathic epilepsy
space occupying lesion
cortical malformation,
prior stroke
genetic disorder

IVIg is given if 4 of 7 are fulfilled

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

TYPES OF SEIZURES

CLASSIFICATION BY CAUSE

A. Partial Seizures (Focal / Local)

Simple Partial
Complex Partial
(Partial Seizure +
Impaired Consciousness)
Partial Seizures evolving to Tonic-Clonic
Convulsion

A. Acute Symptomatic
(shortly after an acute insult)
Infection
Hypoglycemia, low sodium, low calcium
Head trauma
Toxic ingestion

B. Generalized Seizures
Absence
(Petit mal)
Myoclonic
Clonic
Tonic
Tonic-Clonic
Atonic

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

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

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

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
st
nd
Febrile seizure in 1 / 2 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

Clinical Features:
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)

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

3x/wk DOT

RESPIRATORY DISTRESS SYNDROME

(Hyaline Membrane Disease)

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

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

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

o Microscopically: diffuse atelectasis, eosinophilic

membrane

Nasal flaring:
o Due to contraction of alae nasi muscles leading to
marked reduction in nasal resistance

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

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

MKD COMPUTATION
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

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)

Wt x mkd x preparation [mg/mL] = mL per dose

e.g.

5ml = 5mL per dose

120mg

Dose x preparation x frequency = mkd

weight
Paracetamol Drops = Wt: move 1 decimal
point to the left
Age
Wt
1
10 kg
2
12
3
14
4
16
5
18
6
20

Caution & Contraindications

Increased ICP
Bleeding diasthesis
Traumatic Tap
Overlying skin infection
Unstable patient

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)

* If per day, divide total (mL) by the # of divided doses

Complication
Local pain
Infection
Bleeding
Spinal fluid leak
Hematoma (spinal subdural hematoma
Spinal headache
Acquired epidermal spinal cord tumor

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)

12kg x 10mg

1 drop
1 teaspoonful
1 tablespoonful
1 wineglassful
1 glassful
1 grain
1 pint
1 quart
1 ounce
1 Kg
1 lb

= 1/20 mL
= 5 mL
= 15 mL
= 60 mL
= 2 ounces
= 250 mL
= 8 ounces
= 60 mg
= 500 mL
= 1000 mL
= 30 mL
= 2.2 lbs
= 0.45359 Kg

Empirical dose

6 months
tsp TID QID

6 mos 2 yrs
tsp

2-6
1 tsp

6-9
1 tsp

9-12
2 tsp

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

CLINICAL FEATURES
CLASSIFICATION BASED ON SEVERITY
MILD
INTERMITTENT
Exacerbation

Brief

Day-time Sxs
Nightime Sxs
PEFR
PEFR VAR
FEV1

<1x/wk
<2x/mo
>80%
<20%
>80%

MILD
Affects daily
activity &
sleep
>1x/wk
>2x/mo
>80%
20 - 30%
>80%

PERSISTENT
MODERATE
Affects daily
activity &
sleep
daily
>1x/wk
60 - <80%
>30%
60 - <80%

SEVERE
Limits daily
activity &
sleep
continuous
frequent
<60%
>30%
<60%

Breathless

Talks in
Alertness
RR
Accessory
muscles &
retractions

MODERATE

sentences
may be
agitated

- talking
- INF: softer,
shorter, cry,
difficulty
feeding
- prefers
sitting
phrases
usually
agitated

- walking
- can lie down

none

(+)

SEVERE
- at rest
- INF: stops
feeding
- hunched
forward
words
usually
agitated
often >30
mins
(+)

RESPIRATORY
ARREST

Imminent

drowsy /
confused
bradypnea
(+) thoracoabd
movement