Pedia MKD Notes and Others
Pedia MKD Notes and Others
Pedia MKD Notes and Others
Ipratropium
- only for moderate to severe
Normal RR (PALS) Laryngoscope blade (straight or Miller) exacerbations
Age Breaths/min #00-1 – premie-2mos - decrease airway secretions
Infant <1yo 30-60 #1 – 3mos-1yo - give early but no benefit has been shown
Toddler (1-3) 24-40 #2 - >2yrs from repeated doses
Preschooler (4-5) 22-34 #3 - >8yrs 4. steroids
School age (6-12) 18-30 ETT 5. Epinephrine
Adolescent (13-18) 12-16 Size = (Age/4) + 4 - 0.01ml/kg SC or IM (1:1000; max 0.5ml)
Depth of insertion (cm) = ETT size x 3 every 15min up to 3 doses
Normal Heart Rate (PALS) Uncuffed ETT of rpxs<9yo
Age Awake Mean Asleep - attempts should not exceed 30secs Magnesium sulfate
Verify ETT placement - 25-75mkdose IV or IM (max 2g)
NB-3 mos 85-205 140 80-160
- observe chest wall movement infused over 20min, q4 or 6 up to 3-4 doses
3mo-2yr 100-190 130 75-160
- auscultation in both axillae and epigastrium - smooth muscle relaxant
2-10yrs 60-140 80 60-90
- end-tidal CO2 detection - CI – significant hypotension or with
>10yrs 60-100 75 50-90 - improvement in O2 sat renal insufficiency
- CXR
ABG - repeat direct laryngoscopy to visualize ETT * a normalizing PCO2 is a sign of impending respiratory failure
pH 7.35-7.45 - intubation of those with acute asthma is dangerous and should
pCO2 35-45 mmHg NGT be reserved for impending respiratory failure
pO2 80-100 mmHg - from nose to jaw angle to xiphoid - hypotension is the result of air trapping, hyperinflation –
HCO3 22-26 meq/L decpulmo venous return
O2 sat >85% Bag mask ventilation - tx – reduce lower airway obstruction
- 20 breaths/min (infants 30)
Initial MV set-up (PALS) PALS
Oxygen 100% * bradycardia requiring chest compression <60
Tidal Volume 6-15 ml/kg Tachycardia >240bpm suggests tachyarrythmia ET
Inspiratory Time 0.6-1 sec Cuffed
Peak Inspiratory 20-35 cm H2O Hypotension = systolic BP < [(age x2) + 70] Age (yrs)/ 4 + 3.5
pressure Uncuffed
Respiratory Rate Infants 10-30cpm Allergic emergencies Age (yrs)/ 4 + 4
Children 16-20cpm
Adolescents 8-12 1. Epinephrine Bag
PEEP 2-5 cm H2O - 0.01ml/kg (1:1000) IM One-one thousand two-one thousand three-
- max 0.5ml one thousand bag
- repeat every 5min as needed
Effects of Ventilator Setting Changes - site of choice – lateral aspect of thigh due Class I – high-quality CPR
to its vascularity IIa – shock
Ventilator Setting Changes Typical Effects on Blood Gases 2. Histamine-1 receptor antagonist IIb – medications
- diphenhydramine 1-2mg/kg IM, IV or PO
PaCO2 PaO2
3. Steroids to prevent late phase of allergic Defibrillation
↑ PIP ↓ ↑
response 1. 2 J/kg
↑ PEEP ↑ ↑
4. Racemic epinephrine 0.5ml inhaled for signs 2. 4 J/kg
↑ RATE (IMV) ↓ Minimal↑ of upper airway obstruction 3. 10 J/kg
↑ I:E Ratio No Change ↑
↑ FiO2 No Change ↑ Respiratory Emergencies
st
1 2 minutes
↑ Flow Minimal↓ Minimal↑ - HQ CPR
↑ Power (in HFOV) ↓ No change 1. O2 to keep saturation >95% - Shock 2 J/kg
↑ PAW (in HFOV) Minimal↓ ↑ 2. Inhaled B-agonists - No meds
After 2 minutes Needling – 2nd ICS, MCL Indications for Imaging in Closed Head Injury
- Stop, Analyze, Switch D - displacement Age <2 yrs GCS <14 or altered mental status Obtain Head CT
or palpable skull fracture
- HQ CPR O - obstruction
occipital, parietal, or temporal observation vs head CT
- Shock – 4 J/kg P - pneumothorax scalp hematoma or Hx of LOC
- HQ CPR E – equipment failure >5sec or severe mechanism of
injury or not acting normally per
- Meds
parent
1. Epi 0.1ml/kg (1:10,000 + 5ml NSS) Induced therapeutic hypothermia None of signs or symptoms listed No head CT
o
2. amiodarone 5mkd - PNSS 30cc/kg at 4 above
o > 2yrs GCS <14 or altered mental status obtain head CT
- Core body temp 32-34 C x 12-24h
or signs of basilar skull fracture
Hx of LOC or vomiting, or severe observation vs head CT
Cardioversion Glasgow Coma Scale mechanism of injury or severe
- for tachyarrhythmias Activity Best Response headache
Eye Opening None of signs or symptoms listed No head CT
Spontaneous 4 above
To speech 3
SVT – no P wave, narrow QRS, To pain 2 Burn
>220 bpm infant, >180 children None 1
Verbal Superficial - epidermis only
regular rhythm
Oriented 5 - erythema, pain
Confused 4 - sunburn or minor scalds
Stable Inappropriate Words 3
- not included in estimate of surface
1. physio – vagal maneuver Nonspecific sounds 2
None 1 area burned
ice on forehead – 10s
Motor Superficial partial - damages, but does not destroy
2. pharma Follows commands 6 thickness epidermis and dermis
adenosine 0.1mkd (max 6) Localizes pain 5
- intense pain, blisters, pink to
0.2mkd (max 12) Withdraws to pain 4
Abnormal flexion 3 cherry red skin, moist and weepy
Unstable
Abnormal extension 2 Deep partial thickness - epidermis and dermis
- synchronized cardioversion None 1
st - intense pain
1 – 0.5 J/kg Modified Coma Scale for Infants
nd - dry and white
2 – 1 J/kg Activity Best Response
Full thickness - all layers of skin
- sedate if conscious (midaz, diaz, eto) Eye Opening
Spontaneous 4 - charred black color
- press SYNC
To speech 3 - skin grafting required
Primary Assessment To pain 2
A – airway None 1
B – RR, O2 sat, effort, BS Verbal
C – HR, BP, central and peripheral pulses, CRT Coos, babbles 5
Irritable 4
D – alert, voice responsive, pain responsive, unresponsive Cries to pain 3
E – temp, rashes Moans to pain 2
None 1
Respiratory failure – inadequate Motor
Normal spontaneous 6
oxygenation and/or ventilation movement
Withdraws to touch 5
Respi failure – dec rate and effort Withdraws to pain 4
Respi distress – inc rate and effort Abnormal flexion 3
Abnormal extension 2
None 1
Shock
Severity
Compensated – poor perfusion
Hypotensive – poor perfusion, low BP
Irreversible
Burn assessment chart Drips
Dopa, Dobu, Epi Ludan’s
= wt x TFR / 24hrs = ___ cc/hr
3 x desired dose x wt x rate Weight (kg) TFR
12.5 dobu 0-3 75
40 dopa 3-10 100
1 epi 10-20 75
= ___ ml + d5W = 50 cc to run at rate ___ 20-30 60
30-40 50
>40 40
Albumin
>50 30
Wt x (1g/kg) x 100 / prep (5, 20, 25%)
= __ cc x 4hrs
Normal Urine Output
Infants and Young Children 1.5-2
FLUIDS and ELECTROLYTES
ml/kg/hr
Dehydration
No Dehydration Some Severe Older Children and 1 ml/kg/hr
Gen condition Well, alert Restless, irritable Lethargic, Adolescents
unconscious,
floppy
Eyes Normal Sunken Very sunken, dry
Sodium Correction
Tears Present Absent Absent Deficit = (desired – actual) x 0.6 x wt
Mouth and Moist Dry Very dry Maintenance = wt x 2-3mEqs
FLACC pain scale Tongue
Na req = D + M
Categories Scoring Thirst Drinks normally, Thirsty, Drinks Drinks porrly, not
0 1 2 not thirsty eagerly able to drink
FACE No particular Occasional Frequent to Skin Pinch Goes back quickly Goes back slowly Goes back very ___meqs= 50meqs
slowly X (cc) 20 ml
expression or grimace or constant
Body wt. loss <5 5-10 >10
smile frown, quivering Est. Fluid deficit Up to 50 50-100 >100
withdrawn, chin, clenched Potassium Correction
disinterested. jaw. 1. Deficit = (desired – actual) x 0.6 x wt
LEGS Normal Uneasy, Kicking, or
Intravenous Fluids
Maintenance = wt x 2mEqs
position or restless, tense. legs drawn up. Na K Cl lactose
K req = D + M
relaxed. IMB 25 20 22 23
ACTIVITY Lying quietly, Squirming, Arched, rigid NM 40 13 40 16
normal shifting back or jerking. ___meqs = 40 meqs
LR 130 4 109 28 X (cc) 20 ml
position and forth,
0.3 51 - 51 -
moves easily. tense.
CRY No cry, Moans or Crying 0.45 75 - 75 - 2. 40-60meqs/wt/24 = __ kir (0.1-0.3)
(awake or whimpers; steadily, 0.9 154 - 154 - TFR (Ludan’s)
asleep) occasional screams or NR 140 5 98 50
complaint sobs, frequent
X = K per L of IVF = ___ meqs
complaints. Holliday-Segar Tfr
CONSOLABILITY Content, Reassured by Difficulty to
relaxed. occasional console or
Weight ml/kg/day ml/kg/hr
st
touching comfort 1 10kg 100 4 40 or 60 – x = meqs to be added in IVF
nd
hugging or 2 10kg 50 2 Kcl = 2meqs/mlDurule = 10meqs/durule
being talked to, >20 20 1
distractable. Hypocalcemia
Calcium gluconate
100mg/ml (10%)
200-500mkD IV q6
HCO3 correction CARDIOLOGY IVIg
= wt x 0.3 + BE 2.5g/50ml
- ½ SIVP, ½ x 30min drip Murmur Test dose 1. __ml x 30min
Max – 50 meqs Grade Description 2. __ ml x 30 min
- metab acidosis – pH <7.25 1/6 Very faint Then remaining ____ x 11hrs to run at __.
pCO2 <15 2/6 Quiet, but heard immediately upon placing steth on Another line solely for Ig
BE >6 chest Main line on KVO
3/6 Moderately loud VS q15min x 1h then q30min x 2h then q1
Dextrosity 4/6 Loud
Di = DD – DA 5/6 Very loud, may be heard with steth partly off the chest 1. wt x 0.02 x 30 = __ ml
H-L 6/6 Heard even with steth entirely off the chest 2. wt x 0.04 x 30 = __ ml
D7.5 - 0.055
D10 – 0.11 Max = 0.06 cc/kg/,om
Abnormal Heart Sounds
D12.5 – 0.17
• Widely Split S1:Ebstein’s anomaly, RBBB
• Widely Split and Fixed S2:Right ventricular volume overload Phlebotomy
GIR
(e.g., ASD, PAPVR),pressure overload (e.g., PS), electrical delay in
= PT 8-10, FT 6-8 Polycythemia>0.65 Hematocrit
RV contraction (e.g., RBBB),early aortic closure (e.g., MR),
= dextrosity x 0.167 occasional normal child
Wt (kg) Est Blood Volume x (actual Hct – desired Hct)
• Narrowly Split S2:Pulmonary hypertension, AS, delay in LV
= dextrosity x (cc/hr) ActuaHct
contraction (e.g.,LBBB), occasional normal child
Wt (kg) x 6 • Single S2:Pulmonary hypertension, one semilunar valve (e.g., EBV x wt x 0.1-0.2
pulmonaryatresia, aortic atresia, truncusarteriosus), P2 not
Hyponatremia Jones Criteria (Rheumatic Fever)
audible (e.g., TGA, TOF,severe PS), severe AS, occasional normal
Major Minor
child Subcutaneous nodules Clinical
Deficit = (desired – actual) (0.6) (wt) • Paradoxically Split S2:Severe AS, LBBB, Wolff-Parkinson-White polyarthritis Arthralgia
Maintenance = wt x 2 Erythema marginatum Fever
syndrome(type B)
Na req = D + M Carditis Lab Findings
• Abnormal Intensity of P2:Increased P2 (e.g., pulmonary Chorea elevated ESR, CRP
hypertension),decreased P2 (e.g., severe PS, TOF, TS) Plus
1. Na req x 1000/Na in IVF in 1L = x supporting evidence of antecedent group A strep infection
• S3:Occasionally heard in healthy children or adults, or may
2. x/rate = __ hrs correction
indicate dilatedventricles (e.g., large VSD, CHF)
• S4:Always pathologic, decreased ventricular compliance DERMATOLOGY
Hypokalemia
Primary
Kawasaki Disease
1. Deficit = Wt x TBK (50 meq/kg) x K Criteria:
macule/ patch small flat lesion with altered color (<1cm)/ large macule
papule/ plaque elevated, well-circumscribed lesion (<1cm)/ large papule
K = < 3meq/L – 0.05
Fever persisting at least 5 days nodule/ tumor mass in dermis or subcutaneous fat/ large nodule
K = < 2.5meq/L – 0.10
Presence of at least 4 principal features vesicle/ bulla blister with transparent fluid/ large vesicle
K = < 2meq/L – 0.20 wheal erythematous, well-circumscribed, raised, erythematous
1. Changes in extremities lesion that appears and disappears quickly
Maintenance Acute – erythema of palms, soles; edema of hands and feet Secondary
= wt x 2-3meq/kg/day
Subacute – periungual peeling of fingers, toes in weeks 2-3 Scale small, thin plate of horny epithelium
K req = D + M Pustule well-circumscribed elevated lesions filled with pus
2. Polymorpous exanthema
Crust exudative mass consisting of blood, scale and pus
3. Bilateral bulbar conjunctival injection without exudates
2. rate of IVF x 24h x (6-8meqs) = X Ulcer erosion of dermis and cutis with clearly defined edges
4. Changes in lips and oral cavity Scar formation of new connective tissue after damage to
100ml
5. Cervical lymphadenopathy (>1.5cm), usually unilateral epidermis and cutis, leaving permanent change in skin
KIR = x/24/wt = _____ Excoriation surface marks often linear sec to scratching
Fissure linear skin crack with inflammation and pain
- 2d echo should be considered in any infant <6mos with fever of
3. x div 24 = ____ meqs/hr
>7 days’ duration, lab evidence of systemic inflammation, and
4. K req = hrs of correction no other explanation for the febrile illness
meqs/hr
Calculate volume of pRBC GUIDELINE FOR SPACING LIVE AND INACTIVATED VACCINES
Volume of pRBC (ml) = Antigen Combination Minimum Interval Between Doses
EBV (ml) x (desired-actual Hct) >2 inactivated or None, can give simultaneously
Hct of pRBCs inactivated and live
>2 live parenteral 28-day minimum interval, if not
Cryoprecipitate – 1 unit/5kg given at same time
FWB – 15-20cc/kg
pRBC – 10-15cc/kg
Indications for tetanus prophylaxis
Clean, Minor Wound All Other wound
Platelet Concentrate
Prior TT Tetanus TIG Tetanus TIG
0-30kg – 10cc/kg
doses Vaccine Vaccine
>30kg – 3-6 units
Adult – 6 units unknown or yes no yes yes
Child – 0.1-0.2 unites/kg or 1 unit/5-7kg <3
>3, last <5yr no no no no
FFP transfusion ago
- if PT/PTT and control difference is >20 >3, last 5-10 no no yes no
yr ago
Mentzer Index >3, last >10 yes no yes no
= MCV/RBC x 106 yr ago
<12 thalassemia trait, >13 IDA
Juvenile Rheumatoid Arthritis
Naproxen test 1. Age at onset: <16 yr
- 10mkd 2. Arthritis (swelling or effusion, or the
- (+) fever = infection presence of 2 or more of the following signs:
- (-) fever = malignancy limitation of range of motion, tenderness or
pain on motion, increased heat) in ≥1 joints
3. Duration of disease: ≥6 wk
NEONATOLOGY Calcium DOUBLE VOLUME EXCHANGE TRANSFUSION (DVET)
__ cc in 24 hr = Wt x 100 or 200
Apgar 100 Pre-DVET Orders:
0 1 2 Amino Acids (6%) - NPO, insert OGT asceptically
Appearance Blue Pink Completely Wt x (1-3) x 100 - Insert umbicath
pink 6 - Baseline diagnostics
Pulse Rate (-) <100 >100 Cbc w/ apc
Grimace (-) Grimace Cry, cough MgSO4 Bld CS
Activity Limp Some flexion Active LD 200mg/kg PBS, Retic Ct
Respiration (-) Slow, Good, strong MD – 20-40mg/kg Serum Elec w/ Ca
irregular cry = Wt x dose x 24 ABG
* Ballard score most accurate when performed between age 12 250 (prep) Hgt
and 20 hrs Dir & Indir Coomb’s
UVC Bld Typing
NRP Wt x 3 + 9 / 2 + length of stump TB B1
Newborn Screening
size weight AOG
Ideal Body Weight Save blood for chromosomal analysis if needed
2.5 <1000g <28
Preterm – DOL – 14 d x 20-30 g/day + BW - Prepare 1 U FWB properly typed & x-matched with
3 1-2 kg 28-34
Fullterm – DOL – 10 d x 30 g/day + BW mother’s BT (O +)
3.5 2-3 kg 34-38
- Hook patient to continuous pulse oximeter
3.5-4 >3 kg >38 Breastfeeding jaundice
Tip to lip – wt in kg + 6 -
st
1 week of life
- caloric deprivation and/or insufficient frequency of
feeding Post DVET orders:
Apnea - inadequate quantities of BM to remove bilirubin from - Repeat ABG, Hgt, Blood CS IMMEDIATELY post DVET
- cessation of breathing > 20s or any duration if accompanied by the baby - Repeat CBC, Elec w/ Ca 6 hrs post-DVET
cyanosis, bradycardia, desaturation - accentuated unconjugated hyperbilirubin - May resume BF / MF after 4 hrs if stable
- poor caloric intake
DVET (Double-volume Exchange Transfusion) To compute for aliquots
1. FT 160ml/kg PT 160-200ml/kg Breastmilk Jaundice Wt x 80 x 2 = N
2. Blood is removed through the UAC and an equal volume is - (+) glucoronidase in BM N / 10 ml for Term N/8 ml for Preterm
infused through the UVC Ex. 3.8 kg x 80 (TBV) x 2 = 608
3. vigorous, full-term infants - exchange in 15ml increments ROP 608 / 10 ml = 60.8 aliquots to be pushed
Premature/ less stable – exchange at 2-3ml/kg/min to avoid - BW <1500g, AOG <28weeks; or 1500-2000g w/ OUT IN
trauma to red blood cells unstable clinical course
- at least 2 funduscopic exam MECHANICAL VENTILATOR
Corrected age in preterms -
st st
1 exam – bet 4-6 weeks post natal age w/in 21 -33
rd
CA = Actual age in weeks + 40 – AOG at birth week (whichever is late) *Physiologic Set-up (NEONATES)
= days of life/7 = __ + AOG
Neonat Nutrition PIP 18-26
Cranial Ultrasound AA ____g x 4 = _____ cal PEEP 3-6
Indications Lipids = ___ g x 9 = ___ cal RR 40-60
1. Birth wt < 1200g EBM (20 cal/oz) or 20 cal / 30 ml IT 0.5-0.7
2. PT <27 weeks, requiring ventilator D10 = ____ ml x 0.4 = ___ cal FR 8
3. asphyxia with CNS manifestations D7.5 = ___ ml x 0.3 = ___ cal
4. PT <36 wks with head trauma D5 = ____ ml x 0.2 = ____ cal **Management
5. full and bulging fontanelle Pneumothorax dec PIP and PEEP
6. PT with apnea (1-2 days)
7. seizure Respi Acidosis Inc RR and TV
Dec Dead Space
Respi Alkalosis dec RR and TV NOT Recommended crying – late sign of hunger
Inc Dead Space 1. perineal shaving on admission
2. routine enema * do not touch the baby unless there is a medical indication
Met Acidosis = correct if pH <7.2 or HCO3 <12-14 but correlate if 3. routine vaginal douching
pH is compensated 4. routine amniotomy Suctioning
- no proven benefit
nd
Met Alkalosis = know the cause and treat it! 2 stage of labor - may cause apnea, vagal-induced bradycardi, slow-rise in
Check electrolytes, diuretic use? Recommendations oxygen saturation, mucosal trauma with possible increase risk of
Anti-convulsant use? 1. upright position during delivery infection
2. selective (non-routine) episiotomy - only done if:
rd
PRE-EXTUBATION ORDERS 3. prophylactic oxytocin for management of 3 stage of labor - chest not rising with bag and mask ventilation
- Suction secretions per ET/Orem - given within 1 minute of delivery of baby - (+) visible secretions in the mouth and nose
- Epi neb 0.3-0.5 ml + 1.7 – 1.5 ml PNSS (SNS Neb - oxytocin – DOC for postpartum hemorrhage
depending on AMD) 4. delayed cord clamping Vernix – protective barrier to E. coli and GBS
- Do ABG 5. controlled cord traction with countertraction to deliver the
** if patient still has no voice post-extubation, may give placenta Early bathing – removes vernix, hinders crawling effect
neb x 24 hrs 6. uterine massage after delivery of placenta Bathing done at least at 6 hours of life
rd
POST-EXTUBATION ORDERS 3 stage of labor Stomach capacity – 6ml/kg
- O2 Inhalation at 6 lpm/mask NOT recommended At 20-60min – Newborn is ready to be breastfed
st nd
- Monitor VS q15 for the 1 hr, q30 for the next hr, 1. perineal massage in the 2 stage
then q1 thereafter 2. fundal pressure
- ABG 1 hr post-extubation 3. coaching the mother to push NEPHROLOGY
- Epi neb q6 for 24 hrs
Postpartum Care Edema
rd th
- prophylactic antibiotic for 3 or 4 degree perineal tear - sec to excessive accumulation of both Na and water
- early postpartum discharge - causes
Essential Intrapartum Care 1. inability to excrete Na with or without water
NOT RECOMMENDED 2. decreased oncotic pressure
- Mother should have at least 4 prenatal visits - ice packs over the hypogastric area 3. reduced cardiac output
Screen for - manual exploration of uterus 4. mineralocorticoid excess
- anemia, pre-eclampsia, DM, syphilis, HIV - oral methergine
th
Tetanus toxoid – given on 5 month of pregnancy Oliguria
- at least 2 doses before delivery (5 weeks prior to EDC) - UO <300 ml/m2/24h
For Preterm Labor <0.5 ml/kg/hr in children
1. betamethasone 12mg IM q24 x 2 doses <1 ml/kg/hr in infants
CPG 2. dexamethasone 5mg IM q12 x 4 doses
In Labor TFR = BSA x 400-600 + UO in 24h
1. admission when already in active phase Essential Newborn Care BSA = kg x cm/3600 then square root
- 4cm dilated, 2-3 contractions in 10min
2. continuous maternal support Core Steps Nephrotic Nephritic
st
3. upright position during 1 stage of labor (in low risk 1. drying massive proteinuria hypertension
uncomplicated women in labor) 2. skin-to-skin contact hypoalbuminemia hematuria
Supine position - worst 3. properly timed cord clamping edema edema
4. routine use of WHO partograph to monitor progress of labor 4. non-separation of newborn from the mother hyperlipidemia oliguria
5. limit total number of IE to 5 or less for early breastfeeding
st
weighing, bathing, eye care, PE, injections – done after 1 full
breastfeed
Normal BP Values Anti-hypertensives 250 mg / 5 mL PO
Age 95%le Cut-off Agents Preparations Dose & Route 50, 100 cap 5-7 mkd OD IV IM
NB-7d ≥95mmhg, syst Amlodipine 2.5,5, 2.5-10mg OD 1 g vial 55 mkd QID PO
8-30d ≥105 10mg 0.5-2mkd BID-QID 10, 40 mg vial 5-7 mkd Q6 hours
1mo-2y ≥115/75 Captopril 5, 50mg tab 0.05-0.3mg/dose BID-TID PO
2-5y ≥130/80 Clonidine 0.1, 0.2mg 0.1-0.5mg/kg/day OD-BID 300 mkd Q6 hours IV
6-11y ≥135/85 Enalapril5mg tab 0.18-0.56 mg/kg/day OD-BID 5 mkd Q8 hours IV
>12y ≥140/90 Felodipine5,10 mg tab 1-2mkd Q6-12h IV/PO
Furosemide 20, 0.1-0.5 mkdo Q4-IV Methylprednisolone (Pulse, IV)
Hypertension 40mg tab 1-3mkd(mkdo) Q6-12h PO Dose: 30mg/kg/dose x 3 doses monthly
Definition: BP>95(%le) for age on 3 separate occasions Hydralazine 20mg 1mkd BID Prep: 500mg or 1g/vial
Mild 95 (%le) + 10 mmhg amp 0.5-3mcg/kg/min IV inf How to Give:
10 ,25,50mg 0.25-1mkd 4-6 dose, PO Dilute methylpred to make 50ml solution using D5W to run for
Moderate + 10-20 mmHg
Hydrochlor 25, TD: 5ug/KG, MD-25- 1h. Each Dose should be given at least 20hrs apart. Watch out
Severe +20 mmHg
50mg tab 150ugkdQ8h for hypertension. Hold prednisone while on methylprednisolne
Nicardipine 1-2mkd BID-QID Nephrotic Syndrome: Protocol
24 Hr Urine Protein 2.5mg/ml 1mkd BID-TID First Episode
g/24h x 1000- BSA +24hr Nifedipine 5, 10mg cap 50 mg/m2/day, daily 3+ doses (80mg/day) 4-6 wks
Nephrotic Range: ≥ 40mg/m2/hr Prazosin1mg tab 40mg/m2/day every other day 3+ doses 4-6 wks
Propranolol 5, 10
Body Surface Area mg tab Tapering: Remove 5mg every 2-4wks depending on the+/- of
Weight (kg) Formula Spironolactone 25mg tab edema &albuminuria
0-5 Wt x 0.05 + 0.05
6-10 Wt x 0.04 + 0.10 Relapse: 60mg/m2/day daily 3+doses x 2 wks or until (-
10-20 Wt x 0.03 + 0.20 Antibiotics for UTI )CHONuria x 3 consec days then 40 mg/m2/day every other day
20-40 Wt x 0.02 + 0.40 Agent Preparation Dose and Route 4-6 wks then taper
>40 Wt x 0.01 + 0.80 Amikacin 50, 100, 150mg amp 15mkd Q 8 hours IV,
Amoxicillin* 100/ml, 125, IM
Albumin Ampicillin 250/5ml 20-40 mkd TID PO
Dose: 0.5-1 g/kg/dose Cefalexin 250, 500 mg vial 100 mkd Q6 hours IV NEUROLOGY
25% wt x 4= ml of albumin Cefazolin 125/5ml, 250/cap 25-100 mkd QID PO
28% wt x 5 = needed Cefixime 500 mg vial 50 mkd Q8 hours IV Strength Rating Scale
Give Furo 1mkdose IV Cefotaxime 100 mg/5ml 8mkd BID PO 0/5 No movement; no palpable tension at the tendon
Mild, immediately post &4-6 hrs Cefrozil 250, 500mg vial 150 mkd Q8 HR IV 1/5 flicker of movement or < full ROM in a gravity-neutral
Post- transfusion Ceftazidime 125, 250 mg/5mL 30 mkd BID PO plane
Watch out for congestion Ceftriaxone 250, 500 mg vial 150 mkd Q6 hours IV 2/5 movement in a gravity neutral plane
Cefuroxime 250, 500, 1g vial 75 mkd Q24 hours IV 3/5 movement against gravity but not resistance
125 mg/5mL IM
4/5 subnormal strength against resistance
Ciprofloxacin* 500 mg vial 20-30mkd BID PO
Fluid Restriction 5/5 normal strength against resistance
250, 500 mg tab 75-150 mkdQ8 hours
Total Fluid Replacement
CoAmoxyclav* 100, 200, 400 mg IV
BSA(m2) x 400- 500 ml/m2 + UO/24 (ml) Muscle Power
Cotrimoxazole* vial 20-30 mkd BID PO
0 No contraction
228, 475mg/5mL 10-20 mkd Q12
IF with no accurate UO yet: 1 Flicker or trace of contraction
Fluconazole 40-200/80-400 hours IV
BSA x 400-500 ml/m2 2 Active movement, gravity eliminated
Gentamicin mg/5mL 20-40 mkd TID-BID
Nalidixic Acid* 80-400/100-800 mg T – 6-12 mg 3 Active movement, against gravity
IF on Furosemide: 4 Active movement, against gravity and resistance
Nitrofurantoin* tab S – 30-60 mkd BID
BSA x 400 ml/m2 + ½ UO/24hr 5 Normal power
Ticarcillin 50 mg tab PO
Tobramycin* 80 mg ampule 3-9 mkd Q 12 hours
Upper and Lower Motor Neuron Findings Stuporous: appears asleep but rouses to vigorous verbal stimuli, Protein, Sugar
On Exam Upper Lower may awaken spontaneously for brief periods, but Save Specimen
Power dec dec with cloudedsensorium, shows some spontaneous movements Indications
Reflexes inc dec and follows some brief commands Fever, infection, sudden severe headaches, headache worse
Tone inc N or dec Semicoma [Light coma]: no response to verbal stimuli, moves when lying down and improves on standing
Babinski present absent on painful stimuli, reflexes intact (corneals, pupillary), Contraindications
adequaterespiration elevated ICP or mass effect due to concern for herniation,
Reflex Rating Scale Coma [deep coma]: no spontaneous movement or arousal, no infection on site of puncture, blood disorders
0 none reflexes, breathing impaired or absent
1+ diminished (need use of clasped hands/ gritting teeth Bloody tap
International Classification of Epileptic Seizures For every 1000 RBC 1 WBC
to engage reflex
2+ normal For every 800 RBC Inc of 1mg protein
I. Partial seizures (seizures with focal onset) For every 1 WBC 600-1000 RBC
3+ increased (reflexes cross neighboring joint or cross to
A. Simple partial seizures (consciousness unimpaired)
the other side) CSF/blood ratio 0.6
1. With motor signs
4+ hyperactive with clonus
2. With somatosensory or special sensory symptoms
3. With autonomic symptoms or signs
Dermatomes INFECTIOUS
4. With psychic symptoms (higher cerebral functions)
B. Complex partial seizures (consciousness impaired)
S/Sx Laboratory
1. Starting as simple partial seizures
DF Fever with two of the Leukopenia
(a) Without automatisms
following: (WBC <5000 cells/mm3)
(b) With automatisms (such as lip smacking and
- Headache. Thrombocytopenia
drooling, dazed eyes look)
- Retro-orbital pain. (<150 000 cells/mm3)
2. With impairment of consciousness at onset
- Myalgia. Hematocrit rise > 20%
(a) Without automatisms
-Arthtralgia/ bone pain. No evidence of plasma
(b) With automatisms
- Rash. leakage
C. Partial seizures evolving into secondarily generalized seizures
- Haemorrhagic
manifestations.
II. Generalized seizures
- No evidence of plasma
A. Absence seizures: Brief lapse in awareness without
Leakage
postictal impairment (atypical absence seizures may
have the following: mild clonic, atonic, DHF Fever and haemorrhagic Thrombocytopenia
tonic, automatism, or autonomic components) I manifestation <100 000 cells/mm3
B. Myoclonic seizures: Brief, repetitive, symmetrical (positive tourniquet Hematocrit rise > 20%
muscle contractions test) and
C. Clonic seizures: Rhythmic jerking; flexor spasm of evidence of plasma
extremities leakage
D. Tonic seizures: Sustained muscle contraction DHF As in Grade I Thrombocytopenia
E. Tonic-clonic seizures II plusspontaneous <100 000 cells/mm3
F. Atonic seizures: Abrupt loss of muscle tone bleeding. Hematocrit rise > 20%
DHF As in Grade I or II plus Thrombocytopenia
Level of Consciousness III. Unclassified epileptic seizures III circulatory <100 000 cells/mm3
Awake: sensorium fully intact. Asleep at appropriate times. failure Hematocrit rise > 20%
Maintains waking state Lumbar Puncture (weak pulse, narrow
Delirium: Disorientation, fear, irritability, often with pulse pressure,
1. Flat on bed x 4hrs
visual hallucination restlessness).
2. NPO x 4hrs
Drowsy: sleepy but can follow commands DHF As in Grade III plus Thrombocytopenia
3. Send CSF to lab
Lethargic: can follow commands. But very slow IV profound shock < 100 000 cells/mm3
GS/CS
Obtunded: easily falls asleep. Now aware of environment with undetectable BP Hematocrit rise > 20%
Cell count/ Diff count
and pulse
Viral Exanthems Anti-Koch’s 50mg/ml drops
Inh – 200/5 – 10-15mkd 125/250/5
RUBEOLA RUBELLA ROSEOLA ERYTHEMA Rif – 200/5 – 10-20mkd
(MEASLES) (GERMAN INFANTUM INFECTIOSUM
Cefazolin 50-100mkD q8 500mg, 1g vial
MEASLES) (EXANTHEM (5TH DISEASE) Prz – 250/5, 500/5 – 20-40mkd Cefepime 100mkD q12 500mg, 1g vial
SUBITUM)
ETIOLOGY Paramyxoviridae Togaviridae Virus (Prob) Virus (Prob) meninigitic:
(RNA Virus) (RNA Virus) PPD (tuberculin skin test) 150mkD q8
INCUBATION 10-12 days 14-21 days 7-17 days 7-28 days
EPIDEMIOLOGY All ages 6-18 months All ages Rarely >3y/o
- if +, can be read up to 7d Cefixime 8mkD q12-24 20mg/ml
RASH Maculopapular Maculopapular Maculopapular Maculopapular - if -, accurate up to 72hrs only 100mg/5ml
SPREAD Begins face spread Begins trunk … …
DISTRIBUTION rapidly → arms and Last for 24 live virus vax may cause suppression of tuberculin Ceftazidime 90-150mkD q8 250, 500, 1g, 2g
neck-face-legs- hours reactivity; TST postponed at least 4-6weeks Ceftriaxone 50-75mkD q12-24 250, 500, 1g vial
3days
2 mos after measles, mumps, chicken pox, whooping Cefuroxime IV 125/250/5, 250,
PRODOME 3-5 days Mild catarrhal None None
cough 75-150mkD q8 500mg tab
Low-moderate fever Retroauricular,
Hacking cough post cervical,
PO 20 -40mg
Coryza, Conjunctivitis post occipital reading of PPD 20mkD q12
Kopliks after 2-3 days lymphadeno - read perpendicular to the forearm Cefalexin 25-100mkD q6 125/250/5
FEVER PATTERN ↑To abruptly [40- Sudden onset Absent or low
40.5oC] as rash ↑To 39-41oC grade - if -, do not write negative; write 0mm Cetirizine 6mos-2yo 5, 10mg tab
appears ↓To on 3rd –
↓To when rash 4th day as 2.5mg OD 5mg/5ml
reaches legs and feet rashes appear
INFECT PERIOD Isolate – 7th day post 9th-10th day 3rd day of fever
1-5yrs 2.5mg/ml drops
exposure until 5 days post exposure and 1st day of
PEDIATRIC DRUGS 2-5mg OD
after rash appeared (peak) rash
RASH Lateral neck, ears, Absence of PE Rash 3 stages >6yrs
hairline → back, finding to 1.“Slapped Drug Dose Preparation 5-10mg
abdomen→thigh→feet explain fever cheek” Aciclovir IV: 30mkD q8 x 7- 200mg cap
on 2nd trunk and 2. Chloramphenicol IV 125/5 susp; 1g vial
extremities Maculopapular 10days 200mg/5ml 50-75mkD q6
on 3rd day as
face fades
PO: 80 mkDqid x meningitic
3. Lacy or 5d 75-100mkD q6
reticulated
appearance – Amikacin 15-22.5mkD q8 50mg/ml Ciprofloxacin IV 100mg, 250, 500
rash fades
central
125, 250mg/ml 10-20mkD q12
clearing Amoxicillin 25-50mkD q8 250, 500mg cap PO
pruritic last 2- 30-50mkD
39 days 125/250mg/5ml 20-30mkD q12
DESQUAMATION Branny desquamation Minimal Desquamation No Amoxicillin- <3mos TID Clarithromycin 15mkD q12 125/5, 250/5, 250,
[Brownish desquamation rare desquamation
discoloration] Clavulanic Acid 30mkD q12 125/31.25, 500 tab
COMPLICATIONS Otitis media Congenital None None
Pneumonia Rubella
>3mos 250/62.5 Clindamycin IV/IM 75mg/5ml sy
Exacerbate / Sydrome 20-40mkD q8 or BID 25-40mkD q6-q8
Reactivate TB Esp< 14thwk
Myocarditis. SSPE AOG 25-45mkDq12 200/28.5, 400/57 PO
Encephalomyelitis IV 10-30mkD q6-q8
PROPHYLAXIS Immune Serum / ISG 20-30ml to None None
Gamma Globulin pregnant 30mkD q8 Co-trimoxazole IV/PO 80 TMP/400 SMX;
0.25ml/kg ASAP up to exposed only
5 days post-exposure
Ampicillin 100-200mkD q6 250, 500mg vial 8-10mkD q12 40/200/5
meningitic dose: (based on TMP)
200-400mkD q4-q6 Diazepam IV 10mg/2ml amp
PULMONOLOGY Ampicillin- IV-IM 375mg 0.2-0.5mkd 2.5mg rectal gel
Sulbactam 100-200mkD q6 Sulbactam 125, per rectum
Desired CA = 100 – desired FiO2 x PEEP meningitic: ampi 250 0.5mkd
79 200-400mkD q4-q6 750mg Diphenhydramine 1-2mkdose q6 12.5/5, 25, 50 tab
250/500 5mkD q6 50mg/ml amp
FiO2 = CA + 0.21 + pure air 1.5g
Epinephrine IV: 0.01 mg/kg
CA + PA (PEEP) 500/1000
1:10,000 solution
Azithromycin 10mkD OD x 3d 250, 500 tab ET: 0.1 mg/kg
100/5ml 1:1,000 solution
Cefaclor 20-40mkD q8 250, 500cap Erythromycin 30-50 mkD q6 250/5, 500 tab
Famotidine IV 40mg/5ml 2-4mkD q6-8 15-20mkd (max 1g in 24h)
0.6-0.8 mkD q8-12 10, 20, 40 tab (MCU 1mkd) MD
PO PO 5-8mkD
1-1.2mkD q8-12 2-4mkD q12 Valproic Acid PO
Ferrous Sulfate 3-6mkD OD-TID Salbutamol 0.1mkd q6-8 2mg/5ml Initial
Furosemide IV 20mg/2ml 1-2 puffs q4-6 prn 10-15mkD od-tid
0.5-2 mkd q6-12 20, 40 tab Vancomycin 15mkD q6-8 500mg Increments of 5-10mkD at weekly interval
PO Zinc sulfate 10-20mg/day 10/ml MD
1-6mkd q12-24 20/5 30-60mkD bid-tid
Gentamycin 7.5mkD q8 Neuro
Hydrocortisone LD 4-8mkd 100mg, 250mg vial Diazepam Sedative/ Muscle Relaxant Emergency/ Resuscitation/ Cardiac
MD 8mkd q6 IM/IV Epinephrine
(MCU 5mkd) child 0.04-0.2mkd q2-4 Adenosine SVT
st
Hydroxyzine 2mkD q6-8 10/5, 10, 25, 50 adult 2-10mg/dose q3-4 prn 1 dose - 0.1mg/kg rapid push
nd
Ibuprofen 5-10mkd q6-8 100/5, 200/5, PO 2 dose – 0.2mg/kg rapid
40/ml, 100, 200 child 0.12-.8mkD q6-8 push
tab adult 2-10mg/dose q6-12 Atropine Sulfate Bradycardia (symptomatic)
Mebendazole 100mg q12 bid x 50mg/ml IV/IO 0.02 mg/kg
3d; or 20mg/5ml Status Epilepticus ETT 0.04-0.06 mg/kg
500mg single dose 100, 500 tab neonate
Meropenem >3mos 1g 0.3-0.75mkd q15-30min x 2-3 doses (max Toxins/ Overdose
60mkD q8 2mg) <12yo – 0.02-0.05 initially
meningitic >1month then repeat q20-30mins until
120mkD q8 0.2-0.5mkd q15-30 (max <5yo - 5, >5yo - muscarinic symptoms reverse
Metronidazole 35-50mkD q8 x 10d 125/5, 250, 500 10mg)
Montelukast 2-5yrs - 4mg adult >12yo – 0.05 initially then 1-
6-14yrs – 5mg 5-10mkd q10-15min (max 30mg in 8h) 2mg repeat q20-30mins until
>15yrs – 10mg Lorazepam IV/IO/IM muscarinic symptoms reverse
Oxacillin/ PO 500mg 0.05-0.1mkd
Cloxacillin 50-100mkD q6 125/5 Mannitol 0.5-1gkd Rapid sequence intubation
IM-IV Midazolam 6mos-5yo 0.01-0.02 mg/kg
100-200mkD q4-6 0.05-0.1mkd Lidocaine VFib, Pulseless VT, wide-
Paracetamol PO/IV 6-12yrs complex Tachy
10-15mkd q4-6 0.025-0.05mkd Initial dose 1mg/kg loading
Penicillin G IM/IV 1M units/vial >12yrs bolus
100,000-400,000 0.5-2mkd MD 20-50 mcg/kg/miin
U/kg/day Phenobarbital Status Epilepticus infusion
LD ET – 2-3mg/kg/ET
Penicillin V 25-50mkD q6-8 125/5, 250/5, 250,
500 cap 15-20 mkd single or divided doses; give MgSO4 Refractory status asthmaticus
Piperacillin- <6mos 2g/250mg, additional 5mkd q15-30min 25-50mg/kg over 15-30min
MD (max 2g)
Tazobactam 150-300mkD q6-8 4g/500mg
>6mos neonat 3-5mkD od-bid NaHCO3 metab acidosis, hyperkalemia
300-400mkD q6-8 infant 5-6mkD 1 meq/kg slow bolus
1-5yrs 6-8mkd Dobutamine 6 x wt (kg) / 12.5 = __ ml to
Prednisone Asthma 6-12 yrs 4-6mkd add to diluent, to make 100ml
2mkD q12-24 >12yrs 1-3mkd
Anti-inflammatory Sedation: 1-3mkd as one dose, given 60- 1ml/hr delivers 1mcg/kg/,im
0.5-2mkD q12-24 90min prior to proc
Phenytoin LD CHF/ cardiogenic shock
Ranitidine IV 15mg/ml
2-20mcg/kg/min infusion
max 40 Conversion factors
Dopamine 6 x wt (kg) / 40 = __ ml to Hct 0.01
add to diluent, to make 100ml Hgb 0.155
Plt 1101
1ml/hr delivers 1mcg/kg/,im Retic 0.01
TB 17.17
Distributive/ cardiogenic Chole 0.026
shock Crea 88.4
2-20mcg/kg/min infusion FBS 0.56
max 40 TPAG 10
Furosemide Drip OT/PT 0.46
Dilute furo 100mg (20mg/ml) BUN 0.357
in 90ml D5W to run at ___.
CSF Ca 0.5
Norepinephrine 0.6 x wt = __ ml to add to
CSF glc 0.005
diluent, to make 100ml
Hgt 18.18
1ml/hr delivers
0.1mcg/kg/min
hypotensive shock
0.1-2 mcg/kg/min infusion
Insulin Drip 100 units Humulin R in 100ml
PNSS to run at ____
Hyperglycemia
IV infusion
neonat: 0.01-0.1 U/kg/hr
children: 0.5-1 U/kg/day
adolescents: 0.8/1.2 U/kg/day
DKA
IV infusion – 0.1 U/kg/hr
adjusted to serum glucose
Naloxone Narcotic Reversal
total reversal required
2013/ ivy
0.1 mg/kg bolus q2mins PRN
max 2mg