Identifying body parts

During ward rounds, we met a precocious little 15 month old boy.

Nanny: Where is your eye?
Kid points excitedly to eye, and we clap him on.
Nanny: Where is your mouth?
Kid points to lips and makes a pout.
Nanny: Where is your tummy?
Kid points to his belly and we give him a cheer.

Nanny: Where is your bird?

We all look away in awkward silence. We don't know if he actually pointed to it.

Jiahui: I was not expecting that...

Diagnosing Syphyllis

Diagnosis can be DIRECT or INDIRECT

DIRECT 

- microscopic examination of fluids/smears from lesions for T pallidum

- histological examination of tissues or nucleic acid amplification methods (PCR)

INDIRECT

- Serological tests to detect antibodies

- Two categories : NON TREPONEMAL or TREPONEMAL (non specific vs specific)

- Do a non treponemal  test first (measures IgM / IgG formed in response to lipoidal material released from host cells and lipid from treponeme cell surface). If positive then confirm with treponemal test

- A confirmed serological result = presene of Ab but does not indicate stage or present vs past infection

TABLE 3

Interpretation of serological tests for syphilis

Nontreponemal tests	Treponemal tests	Likely interpretation
+	+	Syphilis, yaws or pinta
+	–	False positive – No syphilis
–	+	Primary or latent syphilis; previously treated or untreated syphilis; yaws or pinta
–	–	No syphilis; incubating syphilis

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095002/

Another achievement unlocked

Did my first IV plug x 2 in neonates, one in prem and one in term baby!!! today! :)

Achievement unlocked

Reduced my first pulled elbow today :)

Just like magic!

Vital signs

Formula for weight = (Age x 2) + 8 or 9

Formula for lower limit of systolic BP = ( Age x 2 ) + 70 

Diastolic BP is 2/3 of systolic BP

BP (systolic)

<1m : 60 to 90

1m to 1yo: 71 to 90

1yo to 2yo: 81 to 102

2yo to 3yo: 81 to 105

3yo to 4yo: 81 to 108

4yo to 5yo: 81 to 110

5yo to 6yo: 81 to 111

6yo to 7yo: 82 to 113

7yo to 8yo: 84 to 114

8yo to 9yo: 86 to 115

9yo to 10yo: 91 to 117

10yo to 11yo: 91 to 118

11yo to 12yo: 91 to 120

12yo to 13yo: 91 to 122

13yo to 14yo: 91 to 125

14yo to 15yo: 91 to 127

>15yo: 101 to 130

HR

<3m: 90 to 180

3m to 6m: 80 to 160

6m to 1yo: 80 to 140

1y to 6y: 75 to 135

6yo to 10 yo: 70 to 110

10 yo to 15 yo: 60 to 90

>15 yo: 60 to 90

RR

<3m: 30 to 60

3m to 6m: 30 to 60

6m to 1 yo: 25 to 45

1yo to 6yo: 20 to 30

6yo to 10 yo: 16 to 24

10 yo to 15yo: 14 to 20

>15yo: 12 to 16

SpO2 > 95%

The vomiting child

AETIOLOGY 
Surgical vs non-surgical

Surgical

• Pyloric stenosis
• Intussusception
• Volvulus
• Appendicitis
• Adhesion bands
• Incarcerated hernia
• I/O
• Torsion of testis
• Head injury

Non-surgical

• Sepsis
• CNS 
• space occupying lesion (tumour, abscess)
•  meningitis
• benign intracranial hypertension
• encephalopathy (Reye's)
• ICH (haematoma)
• Metabolic  
• DM
• inborn errors of metabolism
• adrenal insufficiencies
• GE / viral (food poisoning, infections)
• Reflux
• Over feeding / mother craft/ aerophagy
• Drugs/toxins - leading to ileus / encephalopathy
• Vestibular 
• otitis media 
• vestibular dysfunction
• Pregnancy

HISTORY

A) NATURE OF VOMITING

• Bilious/non-bilious/bloody
• Onset - acute, acute on chronic, chronic, recurrent bouts
• Amount, frequency
• Type - projectile, forceful, regurgitation
• Relation to meal - is it soon after feeds
• Appetite
• Any overfeeding? Especially if water is given with milk
• Technique of burping
• First time parents

B) BOWEL HABITS

• Diarrhoea, constipation or stringy stools (Hirschprung)

C) ASSOCIATED SYMPTOMS

• Fever
• Abdo pain, tenderness
• Diarrhoea
• Dysuria
• Headache
• Earache
• Recent injury
• Recent ingestion
• Ataxic gait

D) HYDRATION

• Number of wet diapers
• Last passage of urine or change of diapers
• History of scanty urine

EXAMINATION

A) ASSESS SEVERITY OF VOMITING

• Degree of hydration/acidosis
• Altered mental state (?underlying encephalopathies/metabolic disturbances e.g. hypoglycaemia, acidosis)

B) ABDOMEN

• Distension, mass, bowel sounds
• Tenderness
• Groin for testes and hernias 

C) CNS

• Fontanelles
• Facial/scalp bruising (NAI)
• Cranial nerves
• Fundoscopy for stigmata of NAI and raised ICP
• Nystagmus, gait
• Ears for infection/bleed

INVESTIGATIONS

• Urilax/UFEME - TRO UTI
• FBC - If Fever
• Hypocount - If lethargic/dehydrated
• UEC - If suspecting electrolyte abnormalities or Ix dehydration before discharge. KIV admit if low HCO3 or abnormal electrolytes
• AXR - If suspecting surgical abdomen

DISCHARGE ADVICE

• Strategy for home is small frequent feeds or soft diet of choice
• 1/2 hour after vomit, can give feeds for 1-2 hours
• If <3yo, 15ml Q15min
• If >3yo, 30ml Q15min
• If tolerating can gradually increase amount
• RETURN IF
• persistent vomiting
• Bilious vomiting
• Very little urine over 8 hours
• Increasing lethargy
• Taking poor intake of oral fluids

Vomiting and diarrhoea

Workflow for GE

Cat 2

• <6/12
• SIS 8
• Mild to mod dehydration
• Abdo distension

Cat 2+

• Bilious or bloody vomiting
• Severe abdo pain (6-10)

All else Cat 3

• Can prescribe trial of feeds if has history of vomiting, no abdo pain, episode of vomiting more than 30 min ago

If unstable, Cat 1 Resus

• ABCs
• istat (glucose), FBC, UEC
• Fluid resus with NS 20ml/kg for pre-shock/shock
• Correct hypoglycaemia, hyponatraemia
• After initial resuscitation, maintenance fluid with 5%Dextrose and 0.45% NS or 5% dextrose and 0.9% NS, including fluid deficit over 48H
• Include maintenance fluid
• Admit HD/ICU

Acute gastroenteritis and viral gastritis is a diagnosis of exclusion.

Other important differential diagnoses:

1) Non-GI infections

- pneumonia, UTI, otitis media, septicaemia, meningitis

2) Surgical 

- intussusception, torsion of testis, IO, appendicitis, volvulus, post-op complications

3) CNS

- space occupying lesion, meningitis, encephalitis

4) Metabolic

- DKA, CAH, endocrine, inborn errors of metabolism

5) HUS

6) Toddler's diarrhoea

7) Food allergy/intolerance

8) Hirschprung's enterocolitis

9) IBD

10) Bact GE (dysentry)

11) Myocarditis

12) Poisoning

Rehydration
Determine if min, mild, mod dehydrated

MIN or nil (<3%loss of body weight)

• High risk, definite admission to GW
• Exisiting comorbidity (congenital heart disease, short bowel syndrome, heart failure, ileostomy)
• <6/12 old ,with vomiting >1x past 24H (excludes mild regurgitation and post tussive vomiting), or frequent and large volume stools, or feeding less than normal, or irritable
• High risk, for observation in ED
• <6/12 with criteria for admission but carer refuses (to sign AOR even if pt succeeds in trial of feeds)
• More than 6/12 old with vomiting, unable to retain >1/2 of feeds past 24H and unable to retain at least 1 normal feed past 4H
• If >1yo, start ondansetron (1st line)/supp domperidone (2nd line) before starting ORS
• If <1yo, do not give anti-emetic, start trial of feeds
• Start trial of feeds x 1 hour. Start 30 min after PO ondan/1 hour after supp domperidone
• If pt vomits more than 1x or cannot complete prescribed fluids, ADMIT
• If fulfils discharge criteria, discharge with GE advice, information pamphlet, Lacteol Forte, Hydralyte (chargeable). DO NOT DISCHARGE WITH ANTI-EMETIC
• Low-risk, DISCHARGE 
• <6/12 with no criteria for admission
• >6/12 with no vomiting, can retain >1/2 feeds past 24H and has 1 normal feed past 4H

MILD (3-5% loss of body weight) 

•  If high-risk (<1yo or no competent caregiver),
• ADMIT
• While waiting for admission, start Oral rehydration therapy (ORT) 10ml/kg/hr over 4 hours (over 15 minute aliquots) (e.g. 10kg child requires 100ml every hour, therefore prescribe 25-30ml ORT Q15m x 4H)
• For 1yo or more, with vomiting and unable to retain more than half of normal feeds in 4H, offer oral ondansetron (1st line) or supp domperidone (2nd line) if distressed, before starting ORT
• If no high risk criteria, 
• Give oral rehydration therapy 10ml/kg/hr x 2 hours (over 15 minute aliquots)
• If unable to retain more than half of feeds in past 24H and  unable to retain more than 1 normal feed for past 4H, offer anti-emetic before starting ORT
• If vomits more than 1x or unable to complete prescribed volume over the required period, ADMIT
• If succeeds in 2H of oral rehydration therapy (no vomiting), and fulfils discharge criteria, discharge with instructions to complete the remaining 2H of oral rehydration therapy 10ml/kg/hr, and advise on maintenance oral fluids and GE advice
• Document all advice related to ORT and GE management

MODERATE (6-9% loss of body weight)

a) Vomiting not significant, but fluid loss from diarrhoea > oral intake
b) Vomiting within past 3H, & unable to retain fluids x 6H
- PO ondansetron (1st line) / supp domperidone if distressed before ORT
c) Uncertain of Dx, possibly severely dehydrated , tachypnoeic, drowsiness
- FBC, I-stat, UEC, IV-plug, KIV IV fluids

For moderately dehydrated cases, ADMIT
Expedite admission (S/T shift nurse IC)
- ORT 60-90ml/kg over 6H in 15min aliquots while waiting for admission
- Counsel caregivers: Your child has mod dehydration due to vomiting/diarrhoea/gastroenteritis
- He will need admission for rehydration. Oral route will be tried, but IV will be necessary if PO fails. We will also need to monitor his vital signs, hydration status and ongoing losses through his stool or vomit
- Simple investigations may be done

TRIAL OF FEEDS (if minimally dehydrated) not the same as ORS. If child prefers other liquids, non-fizzy drinks or milk may be given instead.

• If <3yo, 15ml Q 15min x 4  (1 hour)
• If >3yo, 30ml Q 15min x 4 (1 hour)

USE OF ANTI-EMETICS

• Do not use anti-emetics unless vomiting is due to GE
• Do not use if there is 
• post tussive vomiting
• significant abdominal pain/tenderness
• Abdominal distension
• After head injury 
• Do not use if there is nausea without vomiting
• Do not prescribe on discharge

ONDANSETRON

• Risk of accentuating diarrhoea
• Oral fluids may be started 30 min after therapy

DOMPERIDONE SUPP

• Risk of extra-pyramidal symptoms (neck arching, tongue twisting) 
• Oral fluids may be started 1 hour after therapy
• May be less effective if there is ongoing diarrhoea
• Dose 0.1-0.2mg/kg/dose

REVIEW BEFORE DISCHARGE

• If patient vomits 1x, rest 30min before restarting oral fluids trial (trial of feeds 1 hour, ORS 2 hours)
• Review patient for discharge 30min after last feed
• After 2nd episode of vomiting, review for hospitalization

CRITERIA FOR DISCHARGE

• Has retained prescribed oral fluids
• Age appropriate normal mental status
• No vomiting
• No abdominal pain, abdo soft and not distended
• No tachycardia, vitals stable (document!), not toxic
• Not dehydrated
• Reliable, competent caregiver
• Advice on GE/vomiting/abdo pain and when to return 

ON DISCHARGE

• Provide patient leaflets
• Withhold solids for 8H and give small frequent clear feeds
• Explain appropriate types, frequency and volume
• For diarrhoea, calculate how much fluid for each stool
• Emphasise importance of maintaining oral hydration
• Do not give too many medications
• Lacteol forte for diarrhoea
• Paracetamol for fever
• Magnesium carbonate for abdo colic
• Barrier cream (silicon cream or zinc oxide Desitin (non-standard) for perianal excoriation
• If pt has mild dehydration and successfully completed 2 H of ORT, prescirbe another 2H of ORS in sachets for home
• If min dehydrated, advise for clear fluids / diluted milk to be given. Hydralyte is chargeable
• If <6/12, check bottle hygiene and document. Ensure adequate sterilization
• If bloody GE, and child well and >3/12 old, stool CS and Abx not indicated. Discuss with senior. If bloody GE and child <3/12, unwell, ADMIT.