http://drpeds.blogspot.com/
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Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
Tuesday, July 10, 2007
Friday, May 18, 2007
if you are looking for a page and it is not seen here, please check archives or site search. thank you.
if you are looking for a page and it is not seen here, please check archives or site search. thank you.
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
CCF and shock in children
It may sound very surprising but i need to combine these contrast topics to discuss together. As many a times I come across situations where the treating docs even residents and pediatricians alike have made a common mistake of misunderstanding one as another and created problems for the patients and themselves.
How is it possible?
Shock is a situation caused by disparity between fluid volume and capillary bed manifesting as poor pulse and blood pressure.
CCF or congestive cardiac failure is a condition caused due to increased preload following venous overload or cardiac hypo function.
In late stages both these cases can overlap, as shock can cause cardiac dysfunction and cardiac dysfunction due to CCF can lead to shock.
And thus most patients coming in late stages to emergency room are falsly interpreted as shock or CCF especially when the facility for JVP CVP BP measurements is not available or faulty. ( yes its likely- as BP measurement varies with age size of cuff and the person who is taking BP and there are no clear cut levels in any area or age for lowest normal BP. Also CVP may be difficult due to venous access in shock. The CVP reading change with movements , intervention and position of CVP catheter tip which may require an X-ray to confirm.)
In addition the confusion arises due to possibility of presence of congenital heart disease or carditis in children. if the child had a chronic heart disease, its more likely that the decision fo CCF si very often made, as the baseline hepatomegaly and cardiomegaly as a part of chronic heart failure is wrongly interpreted as acute CCF.
Similarly, as in acute carditis or sepsis, raised JVP the only important clinical sign apart from cardiomegaly, is difficult to examine and interpret especially in infants, the failure of heart is interpreted as shock.
As both these conditions present with common findings at some stage
: Tachycardia, poor or weak pulse and low blood pressure and desaturation.
They are easily confused unless an expert decides from various other clinical markers.
why do we need to discriminate the two: CCF and shock?
Because, the treatment differs.
for CCF the main therapy is volume reduction diuresis and judicious blood transfusion and digoxin. And rarely inotropes.
And in shock its fluid pushes and inotropes.
A wrong judgment will take you in wrong direction with vicious events.
Some basic understandings will help not making this mistake:
CCF is more common in association with sever anemia and congenital hearts in infancy mainly below 6 months age. Please confirm the presence of significant hyper dynamic circulation / chest movements /PH with acute cardiomegaly. No cardiomegaly means no CCF. Severe anemia may be a misunderstanding of poor perfusion, please wait till the Hb report before transfusion. The most important finding that’s easy to discriminate is liver tenderness and JVP when measured accurately. Shock will never have liver tenderness. Liver tenderness without raised JVP or cardiomegaly is more likely to be hepatitis than CCF. Acute liver tenderness is an important sign of fluid overload especially in managing dehydrations and shock. Presence of creptations is very important sign provided one gets bilateral symmetrical Velcro crackle in basal interscapular area. If you get asymmetric crepts, its patchy pneumonia and if you get crepts all over chest, its ARDS or pulmonary bleed in shock. Measurement of CVP is by far the most important and standard criterion to discriminate shock and CCF. This may not be possible easily in many developing countries. But an attempt should always be made to get a CVP line in all cases of suspected shock and CCF. CVP more than 10 is surely CCF and CVP less than 5 is surely shock. The conditions where shock and CCF coexist more often are cardiomypopathy, massive myocardial infarctions, sepsis with carditis and aortic stenosis and other obstructive lesions of heart. In such cases the management is highly judicious giving adequate to fewer fluids with maintenance of BP to lowest normal to perfuse periphery and judicious use of diuretics with calculated fluid and salt intake. Most care should be taken not to combine diuresis with fluid restriction; and avoiding peripheral inotropes that will do only harm by increasing peripheral resistance however small dose it is.
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
How is it possible?
Shock is a situation caused by disparity between fluid volume and capillary bed manifesting as poor pulse and blood pressure.
CCF or congestive cardiac failure is a condition caused due to increased preload following venous overload or cardiac hypo function.
In late stages both these cases can overlap, as shock can cause cardiac dysfunction and cardiac dysfunction due to CCF can lead to shock.
And thus most patients coming in late stages to emergency room are falsly interpreted as shock or CCF especially when the facility for JVP CVP BP measurements is not available or faulty. ( yes its likely- as BP measurement varies with age size of cuff and the person who is taking BP and there are no clear cut levels in any area or age for lowest normal BP. Also CVP may be difficult due to venous access in shock. The CVP reading change with movements , intervention and position of CVP catheter tip which may require an X-ray to confirm.)
In addition the confusion arises due to possibility of presence of congenital heart disease or carditis in children. if the child had a chronic heart disease, its more likely that the decision fo CCF si very often made, as the baseline hepatomegaly and cardiomegaly as a part of chronic heart failure is wrongly interpreted as acute CCF.
Similarly, as in acute carditis or sepsis, raised JVP the only important clinical sign apart from cardiomegaly, is difficult to examine and interpret especially in infants, the failure of heart is interpreted as shock.
As both these conditions present with common findings at some stage
: Tachycardia, poor or weak pulse and low blood pressure and desaturation.
They are easily confused unless an expert decides from various other clinical markers.
why do we need to discriminate the two: CCF and shock?
Because, the treatment differs.
for CCF the main therapy is volume reduction diuresis and judicious blood transfusion and digoxin. And rarely inotropes.
And in shock its fluid pushes and inotropes.
A wrong judgment will take you in wrong direction with vicious events.
Some basic understandings will help not making this mistake:
==================================================================
read http://www.nhlbi.nih.gov/health/dci/Diseases/hyp/hyp_whatis.html
read aug 2008 IJP symposium septic shock Indian journal of pediatrics
http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
Friday, April 13, 2007
experience of tetanus cases from mumbai
tetanus once considered to be a deadly medical disease, has come a long way in 20th century, as an easily preventable and effectivey curable disease. So much so that its incidence has disappeared from developed countries.
Even though least cases are seen these days due to effective maternal and childhood immunisation programs; in many areas of developing countries like India, do have significant number of patients presenting as tetanus to tertiary care centers. And few of them have mortalities too.
The once famous Jog and patel clinical score criteria based on fever, tachycardia, number and areas of spasm / trismus; and autonomic disturbances is less often used by many pediatricians; and those who use modify as per their covenience, as the dosages proposed according to clinical score; can be as high as 60 to 80 mg/kg of oral diazepam which is usually not supported by standard textbooks. And also the clinical scores do change very often with or without treatment, a titration of oral dose accordingly doesnt appear a logical solution; as oral absorption of diazepam is erratic. ref 1 2 3
What is more important in management of tetanus is correct diagnosis. A lot many cases are wrongly diagnosed as tetanus; as many people are not awrae of what is trismus and how to check for it. Trismus or lock jaw is a clinical condition that is considered very diagnostic of tetanus; ( and as investigations are often useless in diagnosing tetanus, trismus serves as the sole gold standard diagnostic criteria for tetanus); it is characterised by forecful spasm of jaw muscles with inability to open mouth even under mild pressure; and it is demosntrated in best way by introducing a tongue depressor in mouth; rather attempting to do so; will fail to open mouth. Its very prudent to divert child's attention so that voluntary spasms dont coexist.
Tetanus can be diagnosed in absense of trismus from spasms, rigidity of neck trunk limbs and abdomen; with normal sensorium in a child witha focus of infection and / or history of nonimmunisation.
A wrong diagnosis of trismus will take the child for wrong line of management and vicious cycles of diazepam therapy; and lrolonged hospital stay with addition of multiple medicines; and avoiding all further tests; because once a doc makes diagnosis fo tetanus; usually others dont question it.
How does one make a wrong diagnosis of trismus?
1. false interpretation of voluntary spasm
2. examination by inexeperienced doctor
3. patient may have a seizure and may be interpreted wrongly
4. it can be associated with contradictory neurological signs
5. altered sensorium almost rules out tetanus, unless its following severe hypoxia; which is very rare.
6.if the patient presents to hospital after receiving diazepam and one has no clue to check for trismus
So please reecheck the trismus again, preferably by a senior too; and look for supprtive signs / spasms or contradicting neurological signs.
Another important thing after diagnosis of tetanus, is curtailing a spasm at the earliest. if we donot curtails spasms, they add on to precipitate sever bronchospasms and death.
a spasm should be preferably curtailed only with parenteral diazepam; preferably IV ( diluted with blood) or Intramuscular preferably in deltoid; or per rectal (when IV access is not possible); and never oral.
dose of parenteral or oral diazepam given in most books in 0.2 to 1 mg/kg / dose; which in cases of tetanus appears to be refractory. midazolam doesnt prove promising; and has no benefit in tetanus cases.
Remember diazepam almost never causes of respiratory depression even in higher doses (unless added with another drug like phenobarbitone). Almost all cases of diazepam poisoning recover satisfactorily in a week. ALso, the common morbidity follwoing diazepams is mostly due to its cumulative sedation and vasodilation causing intracranial bleeds.
In tetanus, one may need doses as high as 1-5 mg/kg bolus or tetanus preferably in divisions every 10 minutes (for those who are scared of large dose). to curtail an acute spasms. A spasm can also be controlled by giving muscle relaxants or by causing paralysis; but that make sthe child ventilator dependant.. ( and many are scared of intubations in tetanus cases and go for tracheostomies adding another morbidity.
I had used upto 10mg/kg/dose boluses without causing any problems for curtailing the spasms. Only svere bronchospasms may require high dose diazepam.
Other ways, are to start a low dose diazepam infusions after a bolus diazepam; the infusion are usually 0.2mg/kg/hr for no more than 2 days. dose can be increased gradually; till spasm, but once spasm is controlled for an hour, please taper the diazepam drip rate hourly to avoids intracranial bleeds. switch over earliest to oral or rectal diazepam therapy.
oral diazepam therapies are started at doses of 40, 60 and 80 mg/kg/day in mild , moderate amd sever tetanus respectively. With time, the doses have come down to 20. 40, 60 respectively.
The absorption is errartic with oral. addition of antacids hampers absorption and vomitting and gastritis are frequent complications but are easily treatable.
In the past various antibiotics have ben used for various reasons, but as the clostridia are anaerobes, metronidazole as a single drug chemotherapy usuallky suffices unless another bacerial contamination or pus is documented.
Other CNS dperessants like phenobarbitone, chlorpromazine and chlorzoxazone have been trie in past with erratic regimens without any evidence based benefits. Baclofen is a safer switch over drug due to safety of relaxing mainly skeletal muscles. its action usually is seen by 3rd day, dose range form 0.2 to 1 mg/kg/dose 3-4 times a day.
Tracheostomies especially emergency ones have been associated with significant morbidities.
usually the spasms get controlled in 3-5 days, diazepam can be started tapering once 3 days spasm and rigidity free are observed, but needs to be titrated judiciously. Sometimes spasms may recur again to increase the dose of diazepam. ALl can settle in 2- 4 weeks.
Not to forget, the most important therapy in tetanus management is Tetanus immunogolbulin in high dose to titrate with tetanospasmin; usually 500IU in newborns, 1500IU in infants and 2000 to 3000 IU in children to adults; alongwith primary tetanus immunisation fo child and family.
http://www.pedsccm.org/RARE/Tetanus.html
Lorazepam may be preferable . Limited experience with propofol ,Dantrolene Baclofen Further clinical studies needed. Prompt recognition and treatment of autonomic dysfunction are important in reducing the mortality in this disease.
Author Dr Kondekar Santosh is a pediatrician at Seth G S medical college at KEM Hospital Mumbai india. All of the above opinions are his personel opinions out of personel experience, for more details write to santoshkondekar@kem.edu .
Even though least cases are seen these days due to effective maternal and childhood immunisation programs; in many areas of developing countries like India, do have significant number of patients presenting as tetanus to tertiary care centers. And few of them have mortalities too.
The once famous Jog and patel clinical score criteria based on fever, tachycardia, number and areas of spasm / trismus; and autonomic disturbances is less often used by many pediatricians; and those who use modify as per their covenience, as the dosages proposed according to clinical score; can be as high as 60 to 80 mg/kg of oral diazepam which is usually not supported by standard textbooks. And also the clinical scores do change very often with or without treatment, a titration of oral dose accordingly doesnt appear a logical solution; as oral absorption of diazepam is erratic. ref 1 2 3
What is more important in management of tetanus is correct diagnosis. A lot many cases are wrongly diagnosed as tetanus; as many people are not awrae of what is trismus and how to check for it. Trismus or lock jaw is a clinical condition that is considered very diagnostic of tetanus; ( and as investigations are often useless in diagnosing tetanus, trismus serves as the sole gold standard diagnostic criteria for tetanus); it is characterised by forecful spasm of jaw muscles with inability to open mouth even under mild pressure; and it is demosntrated in best way by introducing a tongue depressor in mouth; rather attempting to do so; will fail to open mouth. Its very prudent to divert child's attention so that voluntary spasms dont coexist.
Tetanus can be diagnosed in absense of trismus from spasms, rigidity of neck trunk limbs and abdomen; with normal sensorium in a child witha focus of infection and / or history of nonimmunisation.
A wrong diagnosis of trismus will take the child for wrong line of management and vicious cycles of diazepam therapy; and lrolonged hospital stay with addition of multiple medicines; and avoiding all further tests; because once a doc makes diagnosis fo tetanus; usually others dont question it.
How does one make a wrong diagnosis of trismus?
1. false interpretation of voluntary spasm
2. examination by inexeperienced doctor
3. patient may have a seizure and may be interpreted wrongly
4. it can be associated with contradictory neurological signs
5. altered sensorium almost rules out tetanus, unless its following severe hypoxia; which is very rare.
6.if the patient presents to hospital after receiving diazepam and one has no clue to check for trismus
So please reecheck the trismus again, preferably by a senior too; and look for supprtive signs / spasms or contradicting neurological signs.
Another important thing after diagnosis of tetanus, is curtailing a spasm at the earliest. if we donot curtails spasms, they add on to precipitate sever bronchospasms and death.
a spasm should be preferably curtailed only with parenteral diazepam; preferably IV ( diluted with blood) or Intramuscular preferably in deltoid; or per rectal (when IV access is not possible); and never oral.
dose of parenteral or oral diazepam given in most books in 0.2 to 1 mg/kg / dose; which in cases of tetanus appears to be refractory. midazolam doesnt prove promising; and has no benefit in tetanus cases.
Remember diazepam almost never causes of respiratory depression even in higher doses (unless added with another drug like phenobarbitone). Almost all cases of diazepam poisoning recover satisfactorily in a week. ALso, the common morbidity follwoing diazepams is mostly due to its cumulative sedation and vasodilation causing intracranial bleeds.
In tetanus, one may need doses as high as 1-5 mg/kg bolus or tetanus preferably in divisions every 10 minutes (for those who are scared of large dose). to curtail an acute spasms. A spasm can also be controlled by giving muscle relaxants or by causing paralysis; but that make sthe child ventilator dependant.. ( and many are scared of intubations in tetanus cases and go for tracheostomies adding another morbidity.
I had used upto 10mg/kg/dose boluses without causing any problems for curtailing the spasms. Only svere bronchospasms may require high dose diazepam.
Other ways, are to start a low dose diazepam infusions after a bolus diazepam; the infusion are usually 0.2mg/kg/hr for no more than 2 days. dose can be increased gradually; till spasm, but once spasm is controlled for an hour, please taper the diazepam drip rate hourly to avoids intracranial bleeds. switch over earliest to oral or rectal diazepam therapy.
oral diazepam therapies are started at doses of 40, 60 and 80 mg/kg/day in mild , moderate amd sever tetanus respectively. With time, the doses have come down to 20. 40, 60 respectively.
The absorption is errartic with oral. addition of antacids hampers absorption and vomitting and gastritis are frequent complications but are easily treatable.
In the past various antibiotics have ben used for various reasons, but as the clostridia are anaerobes, metronidazole as a single drug chemotherapy usuallky suffices unless another bacerial contamination or pus is documented.
Other CNS dperessants like phenobarbitone, chlorpromazine and chlorzoxazone have been trie in past with erratic regimens without any evidence based benefits. Baclofen is a safer switch over drug due to safety of relaxing mainly skeletal muscles. its action usually is seen by 3rd day, dose range form 0.2 to 1 mg/kg/dose 3-4 times a day.
Tracheostomies especially emergency ones have been associated with significant morbidities.
usually the spasms get controlled in 3-5 days, diazepam can be started tapering once 3 days spasm and rigidity free are observed, but needs to be titrated judiciously. Sometimes spasms may recur again to increase the dose of diazepam. ALl can settle in 2- 4 weeks.
Not to forget, the most important therapy in tetanus management is Tetanus immunogolbulin in high dose to titrate with tetanospasmin; usually 500IU in newborns, 1500IU in infants and 2000 to 3000 IU in children to adults; alongwith primary tetanus immunisation fo child and family.
http://www.pedsccm.org/RARE/Tetanus.html
Lorazepam may be preferable . Limited experience with propofol ,Dantrolene Baclofen Further clinical studies needed. Prompt recognition and treatment of autonomic dysfunction are important in reducing the mortality in this disease.
Author Dr Kondekar Santosh is a pediatrician at Seth G S medical college at KEM Hospital Mumbai india. All of the above opinions are his personel opinions out of personel experience, for more details write to santoshkondekar@kem.edu .
Wednesday, April 11, 2007
malabsorption syndromes: a clinical approach in children
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
Tuesday, April 10, 2007
peditips
visit pediatric medicine tips pediatric tips clinical tips child health tips archives at
http://peditips.blogspot.com/2007/01/this-page-is-meant-mainly-for-clinical.html
new tips will be posted at this apge.
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
http://peditips.blogspot.com/2007/01/this-page-is-meant-mainly-for-clinical.html
new tips will be posted at this apge.
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
Friday, April 06, 2007
early postnatal care after birth
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
Tuesday, January 30, 2007
inotropic support , dopamine , and other inotropes in children
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
http://www.aic.cuhk.edu.hk/web8/inotropes.htm
http://funnytrivias.blogspot.com
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
Department of Pediatrics: KEM Hospital: home page
Dear Pediatricians and resident doctors,
Receptor pharmacology
| Agent | Alpha1 | Alpha2 | Beta1 | Beta2 | Dopamine |
| Dobutamine | + | + | ++++ | ++ | 0 |
| Dopamine | ++/+++ | ? | ++++ | ++ | ++++ |
| Epinephrine | ++++ | ++++ | ++++ | +++ | 0 |
| Norepinephrine | +++ | +++ | +++ | +/++ | 0 |
| [6 ><> |
| It can also be calculated as: Amount of dopamine to be added to 100 ml of IV fluid = 6 multiplied by wt and desired dopamine rate in ug/kg/min; divided by IV fluid rate in ml/hr |
| Precautions: Before starting dopamine drip; elliminate low volume states by giving two pushes of 20cc/kg of RL/ NS Presence of good urine output justifies good renal perfusion and rules out need for dopamine. Pulse may go weak on dopamine due to its vasoconstrictor action if it were started on low volume. Always start with 5ug/kg/min then go higher as reqd within 30 min. It should be avoided or used judiciously in cases of pulmonary edema, as it increases PVR. |
| CALCULATIONS ARE SAME FOR DOBUTAMINE, FOR Ad; USE 0.6 INSTEAD OF 6 |
| Agents | Site of Action | Dose mcg/kg/min | Effects |
|---|---|---|---|
| Dopamine | Dopaminergic Beta alfa>beta | 0.5-4 4-10 11-20 | Renal vasodilator Inotrope Peripheral vasoconstrictor Increased PVR Dysrhythmias |
| Dobutamine | Beta1 & Beta2 | 1-20 | Inotrope Vasodilatation Beta2 Decreases PVR weak Alfa activity Tachycardia & Extrasystoles |
| Isoproterenol | Beta1& Beta2 | 0.05-2.0 | Inotrope Vasodilatation Decreases PVR MVO2 Dysrhythmia |
| Epinephrine | Beta > Alfa | 0.05-2.0 | Inotrope Tachycardia Decreased Renal Flow MVO2 Dysrhythmia |
| Norepinephrine | alfa > Beta | 0.05-2.0 | Profound constrictor Inotrope MVO2 SVR |
| sodium Nitroprusside | Vasodilator: Arterial greater than Venous | 0.5-10 | Rapid onset;short dur.n Incrreases ICP V/Q mismatch Cyanide toxicity |
| Nitroglycerin | Vasodilator: Venous greater than Arterial | 1-20 | Decreased PVR Increases ICP |
| PGE2 | Complex | 0.05-0.2 | Vasodilation Open Ductus Arteriosus |
| Amrinone | PDE3 Inhibitor | 1-20 | Inotrope Chronotrope Vasodilatation |
A simple calculation for Dopamine drip--
To keep rate upto 5 mcg/kg/min add 9 small tuberculin units of dopamine per kg body weight for 12 hr drip.
if you need double rate,double the amt of dopamine i.e. for 10mcg/kg/min add 18 OTU/kg/12 hr drip
now as far as iv fluids are considered:
can be modified as below:
(after first month of life)
2.5 kg = 10 ml/hr = 10 udps/min
5kg = 20ml/hr = 20udps/min
7kg = 30 ml/hr = 30 udps/min
10kg = 40 ml/hr = 40 udps/min
15 kg = 50ml/hr = 50 udps/min
20 kg = 60 ml/hr = 60 udps/min
in between for each Kg add 2 microdrops extra/minute
Thanks to 1ml/hr = 1 udropper minute,
as one macrodrop = 16 microdrops;
1ml= 60 microdrops # 60seconds = 1 minute
For Dopamine drip=
0.0015 × wt. × Rate × duration = ml of Dopamine (for 1ml of Dopamine = 40mg) to be added to the syringe pump.
Weight = in Kg
Rate = µg/kg/min of Dopamine
Duration = in hours
For Dobutamine drip =
0.0048 × rate × duration × wt. = ml of Dobutamine (for 1ml = 12.5 mg of Dobutamine) to be added to the syringe pump.
Weight = in Kg
Rate = µg/kg/min of Dopamine
Duration = in hours
http://www.aic.cuhk.edu.hk/web8/inotropes.htm
This page is meant mainly for clinical tips.. pediatric medicine tips and tricks
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
====================================================
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
====================================================
02/05/2007
all our PICU cases are dying of pulmonary hemorrhages after a weeks stay.
tip: u r surely dealing with klebsiella sepsis, reason is poor handwashing and hygiene in ICU. the cause can be heavy dose of sedations occasionally and if with pneumothorax may be high presure settings in children (can be easily avoided by switching to higher frequencies than pressures). In most such cases, radiologist will report X ray as ARDS, and if the adequate antibiotics dont reach in advance before the bleed, surely death is a sequalae.
====================================================
01/05/2007
my patient is on dopamine and dobutamine both max limits still the pulses are not felt , BP is normal.
========= dear, when BP is normal there is no need for inotropes. if pulses are not felt or dusky, please cut o`ff the inotropes as they are harming the patient. if BP were low in addition, i would like u to make sure that there is no extra dose of diuresis or the fluids are restricted, cos in these situations of hypovolemiua, inotropes wont work.
06/07/2003
Most of my patients with fever chills, who I send home on chloroquine; they come back within 24 hrs saying no effext! Is it chloroquine resistance?:
TIP:not resistance but lack of some precaution on your part.; See it takes at least 26 hrs to get control over fever after starting chloroquine. If you had taken time to tell pt that fever may recur in 36 hrs, he wouldnt come to you at the next spike of fever. Also some other imp points which you need to tell him are: Shivering/sweating is nothing to worry (!), blankets may aggrevate temp.; Vomitting may be common following tablets. (Why dont you habituate yourself to give the first dose of chloroquine in hospital itself?. Its prefered that it should be given with food but even glucon D suffices; also countering the hypoglycemia effect)
====================================================
23/06/2003
how will you suspect URTI in a <5 child without opening his mouth:
TIP:pediatricians are best magicians.; a toddler or an infant with URTI doesnt open his mouth often ; infact he keeps it tight; if opened- that just to cry. The vomiting associated with same is just bcos child had not swalloed the contents that were introduced in his mouth in last few hr
====================================================
23/06/2003
a 2 yr boy presents with fever and loose motions vomitting and excessive crying; no dehydration, motions semisolid to loose but not responding to hydration and IV metro; its 3rd day today and baby is still excessively crying, CSF study is normal :
TIP:small precautions always avoid big mistakes; If you had checked babies throat or ear with caution; you wouldnot hv missed the parenteral diarhoea. Excessive crying and vomitting persisted bcos you never treated his URTI.
====================================================
30/05/2003
what is the commonest cause of vomitting in children, that doesnt respond to antiemetics?:
TIP:URTI!!; the way to deal vomitting in such cases is: saline neb/soothing, liquid sweet diet for a day or two and slow feeding for a day or two ! lo!!! no vomitting!!!
====================================================
17/05/2003
what are the four commonest causes of excessive crying?:
TIP:Its natural!! 1. hunger, 2. URTI 3.earache 4.colic;
====================================================
17/04/2003
A breathless child whenever put on O2 hood, becomes restless, hyperactive and throws out everything:
TIP:Its natural!!; in fact its very oddly suffocating... always look for baby's comfort; turn to side, keep him soothed by humidifying O2 and Frequent Nebulisation.or Intermittently give backrest so that he will be oriented in surroundings. Best is to use nasal prongs/or catheter; with it baby can be mobile and think of feeding too. (Also avoids O2 wastage)
====================================================
16/04/2003
Almost every mother tells my baby has always forehead temp, its always there but doesnt come in thermometer. How to approach?:
TIP:Counsel and convince; Children have a rapidly growing brain which has a high BMR which emits heat, and is normal unless body is also warm/hot.
====================================================
14/04/2003
Hyperpyrexia is very common, at times chilren requires high doses of paracetamol, but fever fails to come down even with forehead cold compresses?:
TIP:Cool Down ; Not really, unless sepsis, asphyxia or pontine bleed, other causes like heat stroke are les common. Avoid thick cloths/blankets, take child to open air/fan/AC (despite shivering+/-). keep NORMAL temp compressses over chest and abdomen/back (forehead doesnt help) . Fever has to come down in 20 min with single dose PCM; if doesnt... truly think of other causes
====================================================
07/04/2003
We have a 6 month old baby presented with breathlesness since 24 hrs, not responding to cefitaxim amikacin, xray shows some streaking, RR is 80 what to do?:
TIP:Cool Down ; How could you think its an infection? If fever is there, why do you want to treat a viral bronchiolitis with antibiotics?
====================================================
25/03/2003
Our ventilator patients always need pavlon or midazolam drip, otherwise they fight on ventilator and not maintain saturation:
TIP:avoid breathing against ventilation, 1. Donot keep any child on CMV/IPPV if he has good respiratory drive! => use SIMV/PSV/CPAP as applicable (with minimum rate of 20 which will help even if he fatigues) . 2.At times judicious sedation for SHORT WHILE may be required to allay the anxiety of child! 3. And if a child can pull his tube out , may be he doesnt need it...(just try and see) 4. Did you mistake acidosis as tachypnea?
====================================================
24/03/2003
our Xrays are always over or under exposed, so we could never get exact picture in a case:
TIP:3 simple tricks, 1. try reading the Xray obliquely; by this most pleural effusions seem to be NOT THERE! 2.Read white(overexposed) Xrays against white background(e.g. bedsheet); the white will stand out! 3. Read black xrays against redlight/dimlight; the black will stand out. And the best way is to scan the Xray and see it under changing resolutions in adobe/photoshop, every milimeter of chest will be clearly interpretable.
====================================================
21/03/2003
Its preferable to keep a child with respi distress on ET- O2/T piece if not ventilating by machine:
TIP:NEVER ! Unless the distress in child is bcos of laryngomalacia, the above exercise will in fact worsen distress by narrowing the airway diameter and offering outflow resistance, What is required for such kind of patients is CPAP which can be nasal/pharyngeal (or ET)
====================================================
19/03/2003
patients are difficult to wean from tracheostomy bcos of plenty of secretions:
TIP: WRONG! If the patient has a good gag reflex, and no URT pathology, the patient improves following tracheostomy and in fact patient is able to take the secretions out effectively.
====================================================
18/03/2003
all children with brochiolitis land up with trachiostomy/ ventilator:
TIP: wrong policy and management only lack of patience; willful restraint and insufficient hydration will take you in that direction. physical comfort to child is the best solution.
====================================================
16/03/2003
all children with status epilepticus require a second anticonvulsant:
TIP: very rare. I am sure you must not have loaded the child with enough(20mg/kg) of first anticonvulsant or you must be treating metabolic seizure with anticonvulsants.
====================================================
all children need to be tied to bed, as they frequently remove their RT or put their IV in mouth:
TIP: just give elbow splinting If you dont allow elbow to flex, all this is avoided.
====================================================
breathlessness in a child not improving with Nebulisation,chest is clear:
TIP: do nasal suction nose block is very common.
mother give history of child not taking anything orallyU dont find any reason:TIP: did you see the throat?
whenever a child doesnt open mouth, :TIP:always look for glands and 100% his throat is infected
====================================================
14/03/2003
I always use a proper size laryngoscope, but I cant see larynx/oesophagus easily:
TIP: pass a feeding NG tube, then only other opening is larynx. Hold laryngoscope blade obliquely across the tongue so that it doesnt fall back to hide larynx. And ofcourse cricoid pressure makes it 'done'. AND whenver you are in doubt, remove the tube and give BMV; its phenomenal.
====================================================
The patients i intubated, never survived. or every patient intubated, soon goes on Ad drip:
TIP: Make it a habit to give atropine prior to intubation. . even in dior emergencies, you can always give BMV till its done (most of the time, (it takes only the time taken to open the ET).
====================================================
I could never see enough chest rise while giving BMV:
TIP: Doctor, you either forgot the HEAD TILT CHIN LIFT or the mask is big size.
====================================================
AMBU is useless,as its very difficult to achieve good SPO2 with it:
TIP: Ofcourse yes, and only if you are not using a reservoir.
====================================================
Every patient of TBM and CHD goes on dopamine:
TIP: only if you underestimate/undertreat the dehydration by 'unanition' and restrict the fluid despite diuretics.
my patients on dopamine, always worsen and require higher doses and worsen more:
TIP: they do worsen only if the hydration was not maintained by 2 RL pushes (with maintainance fluids) prior to dopamine. AND also when it was started in presence of severe pulmonary edema.
==================================================
patients with prolonged PT bleed continuously despite, plasma cover:
TIP: please... give a good gastric lavage and enema every day.. and observe for fresh bleeding tendencies. Give a break to Plasma if no bleeding tendencies for 24 Hrs
http://funnytrivias.blogspot.com
====================================================
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
====================================================
02/05/2007
all our PICU cases are dying of pulmonary hemorrhages after a weeks stay.
tip: u r surely dealing with klebsiella sepsis, reason is poor handwashing and hygiene in ICU. the cause can be heavy dose of sedations occasionally and if with pneumothorax may be high presure settings in children (can be easily avoided by switching to higher frequencies than pressures). In most such cases, radiologist will report X ray as ARDS, and if the adequate antibiotics dont reach in advance before the bleed, surely death is a sequalae.
====================================================
01/05/2007
my patient is on dopamine and dobutamine both max limits still the pulses are not felt , BP is normal.
========= dear, when BP is normal there is no need for inotropes. if pulses are not felt or dusky, please cut o`ff the inotropes as they are harming the patient. if BP were low in addition, i would like u to make sure that there is no extra dose of diuresis or the fluids are restricted, cos in these situations of hypovolemiua, inotropes wont work.
06/07/2003
Most of my patients with fever chills, who I send home on chloroquine; they come back within 24 hrs saying no effext! Is it chloroquine resistance?:
TIP:not resistance but lack of some precaution on your part.; See it takes at least 26 hrs to get control over fever after starting chloroquine. If you had taken time to tell pt that fever may recur in 36 hrs, he wouldnt come to you at the next spike of fever. Also some other imp points which you need to tell him are: Shivering/sweating is nothing to worry (!), blankets may aggrevate temp.; Vomitting may be common following tablets. (Why dont you habituate yourself to give the first dose of chloroquine in hospital itself?. Its prefered that it should be given with food but even glucon D suffices; also countering the hypoglycemia effect)
====================================================
23/06/2003
how will you suspect URTI in a <5 child without opening his mouth:
TIP:pediatricians are best magicians.; a toddler or an infant with URTI doesnt open his mouth often ; infact he keeps it tight; if opened- that just to cry. The vomiting associated with same is just bcos child had not swalloed the contents that were introduced in his mouth in last few hr
====================================================
23/06/2003
a 2 yr boy presents with fever and loose motions vomitting and excessive crying; no dehydration, motions semisolid to loose but not responding to hydration and IV metro; its 3rd day today and baby is still excessively crying, CSF study is normal :
TIP:small precautions always avoid big mistakes; If you had checked babies throat or ear with caution; you wouldnot hv missed the parenteral diarhoea. Excessive crying and vomitting persisted bcos you never treated his URTI.
====================================================
30/05/2003
what is the commonest cause of vomitting in children, that doesnt respond to antiemetics?:
TIP:URTI!!; the way to deal vomitting in such cases is: saline neb/soothing, liquid sweet diet for a day or two and slow feeding for a day or two ! lo!!! no vomitting!!!
====================================================
17/05/2003
what are the four commonest causes of excessive crying?:
TIP:Its natural!! 1. hunger, 2. URTI 3.earache 4.colic;
====================================================
17/04/2003
A breathless child whenever put on O2 hood, becomes restless, hyperactive and throws out everything:
TIP:Its natural!!; in fact its very oddly suffocating... always look for baby's comfort; turn to side, keep him soothed by humidifying O2 and Frequent Nebulisation.or Intermittently give backrest so that he will be oriented in surroundings. Best is to use nasal prongs/or catheter; with it baby can be mobile and think of feeding too. (Also avoids O2 wastage)
====================================================
16/04/2003
Almost every mother tells my baby has always forehead temp, its always there but doesnt come in thermometer. How to approach?:
TIP:Counsel and convince; Children have a rapidly growing brain which has a high BMR which emits heat, and is normal unless body is also warm/hot.
====================================================
14/04/2003
Hyperpyrexia is very common, at times chilren requires high doses of paracetamol, but fever fails to come down even with forehead cold compresses?:
TIP:Cool Down ; Not really, unless sepsis, asphyxia or pontine bleed, other causes like heat stroke are les common. Avoid thick cloths/blankets, take child to open air/fan/AC (despite shivering+/-). keep NORMAL temp compressses over chest and abdomen/back (forehead doesnt help) . Fever has to come down in 20 min with single dose PCM; if doesnt... truly think of other causes
====================================================
07/04/2003
We have a 6 month old baby presented with breathlesness since 24 hrs, not responding to cefitaxim amikacin, xray shows some streaking, RR is 80 what to do?:
TIP:Cool Down ; How could you think its an infection? If fever is there, why do you want to treat a viral bronchiolitis with antibiotics?
====================================================
25/03/2003
Our ventilator patients always need pavlon or midazolam drip, otherwise they fight on ventilator and not maintain saturation:
TIP:avoid breathing against ventilation, 1. Donot keep any child on CMV/IPPV if he has good respiratory drive! => use SIMV/PSV/CPAP as applicable (with minimum rate of 20 which will help even if he fatigues) . 2.At times judicious sedation for SHORT WHILE may be required to allay the anxiety of child! 3. And if a child can pull his tube out , may be he doesnt need it...(just try and see) 4. Did you mistake acidosis as tachypnea?
====================================================
24/03/2003
our Xrays are always over or under exposed, so we could never get exact picture in a case:
TIP:3 simple tricks, 1. try reading the Xray obliquely; by this most pleural effusions seem to be NOT THERE! 2.Read white(overexposed) Xrays against white background(e.g. bedsheet); the white will stand out! 3. Read black xrays against redlight/dimlight; the black will stand out. And the best way is to scan the Xray and see it under changing resolutions in adobe/photoshop, every milimeter of chest will be clearly interpretable.
====================================================
21/03/2003
Its preferable to keep a child with respi distress on ET- O2/T piece if not ventilating by machine:
TIP:NEVER ! Unless the distress in child is bcos of laryngomalacia, the above exercise will in fact worsen distress by narrowing the airway diameter and offering outflow resistance, What is required for such kind of patients is CPAP which can be nasal/pharyngeal (or ET)
====================================================
19/03/2003
patients are difficult to wean from tracheostomy bcos of plenty of secretions:
TIP: WRONG! If the patient has a good gag reflex, and no URT pathology, the patient improves following tracheostomy and in fact patient is able to take the secretions out effectively.
====================================================
18/03/2003
all children with brochiolitis land up with trachiostomy/ ventilator:
TIP: wrong policy and management only lack of patience; willful restraint and insufficient hydration will take you in that direction. physical comfort to child is the best solution.
====================================================
16/03/2003
all children with status epilepticus require a second anticonvulsant:
TIP: very rare. I am sure you must not have loaded the child with enough(20mg/kg) of first anticonvulsant or you must be treating metabolic seizure with anticonvulsants.
====================================================
all children need to be tied to bed, as they frequently remove their RT or put their IV in mouth:
TIP: just give elbow splinting If you dont allow elbow to flex, all this is avoided.
====================================================
breathlessness in a child not improving with Nebulisation,chest is clear:
TIP: do nasal suction nose block is very common.
mother give history of child not taking anything orallyU dont find any reason:TIP: did you see the throat?
whenever a child doesnt open mouth, :TIP:always look for glands and 100% his throat is infected
====================================================
14/03/2003
I always use a proper size laryngoscope, but I cant see larynx/oesophagus easily:
TIP: pass a feeding NG tube, then only other opening is larynx. Hold laryngoscope blade obliquely across the tongue so that it doesnt fall back to hide larynx. And ofcourse cricoid pressure makes it 'done'. AND whenver you are in doubt, remove the tube and give BMV; its phenomenal.
====================================================
The patients i intubated, never survived. or every patient intubated, soon goes on Ad drip:
TIP: Make it a habit to give atropine prior to intubation. . even in dior emergencies, you can always give BMV till its done (most of the time, (it takes only the time taken to open the ET).
====================================================
I could never see enough chest rise while giving BMV:
TIP: Doctor, you either forgot the HEAD TILT CHIN LIFT or the mask is big size.
====================================================
AMBU is useless,as its very difficult to achieve good SPO2 with it:
TIP: Ofcourse yes, and only if you are not using a reservoir.
====================================================
Every patient of TBM and CHD goes on dopamine:
TIP: only if you underestimate/undertreat the dehydration by 'unanition' and restrict the fluid despite diuretics.
my patients on dopamine, always worsen and require higher doses and worsen more:
TIP: they do worsen only if the hydration was not maintained by 2 RL pushes (with maintainance fluids) prior to dopamine. AND also when it was started in presence of severe pulmonary edema.
==================================================
patients with prolonged PT bleed continuously despite, plasma cover:
TIP: please... give a good gastric lavage and enema every day.. and observe for fresh bleeding tendencies. Give a break to Plasma if no bleeding tendencies for 24 Hrs
Monday, January 22, 2007
Scarlet fever
http://drpeds.blogspot.com
http://funnytrivias.blogspot.com
Scarlet Red
Isnt all well read !
Japanese RED boy = kawasaki disease
Asian RED boy = scarlet fever
African RED boy = Kwashiorkar ?
Scarlet fever
Has been a major morbidity and mortality
In prepenicillin era; in epidemics
The incidence and severity decreased over years with changed streptococcal virulence in response to newer antibiotics.
Rash develops in fewer than 10% of cases of "strep throat."
incidence
Age 4-8 years peak
By the time children are 10-years-old, 80% have developed lifelong protective antibodies against streptococcal pyrogenic exotoxins.
Scarlet fever is rare in children younger than 2 years, because of the presence of maternal antiexotoxin antibodies and lack of prior sensitization.
Despite incomplete Kawasaki label
Scarlet fever is easy to diagnose..
Seen in kids not exposed often to streptococcal infections; thus not having any antibacterial or antitoxin immunity.
Diagnostic is red ..
Red tonsils red tongue and red rash !
White – red- strawberry tongue
Starts on face, nonpunctate; on trunk it is punctate erythematous boiled lobster appearance
And evidence of Hemolytic Streptococci
Other signs: falsly diagnostic
Circumoral Pallor
Pastia sign
Pin hole peeling
Differentials
If rash is illdefined with mild tonsil = Rubella
If rash is confluent = closer to measles
If exudative tonsillitis = closer to staph
Macular rash = drug rash
Tender nodes = adenitis
Nondiscrete LN = closer to diptheria
If no strept = incomplete Kawasaki
Clinical variants
Mild = ambulatory, fever is major symptom
Moderate = toxic look, with some dysphagia
Severe = bedridden
Septic Scarlet fever = local sepsis/ perf
Toxic Scarlet fever = systemic sepsis
Extrafaucial scarlet fever
complications
ENT purulent –it is, pneumonia , meningitis
Adenitis
Vulvovaginitis
R Nephritis
R Myocarditis
R Polyarthritis
Risk following an untreated streptococcal infection
Acute rheumatic fever : 3% in epidemic 0.3% in endemic scenarios
Glomerulonephritis 10-15%
Easy to treat…
Hemolytic strepts respond promptly to benzyl penicillin and Benzathine Penicillin
10 days oral penicillin
Use of any other drug indicates lack of knowledge on part of the prescriber
Why not….
Other penicillins.. Less effective for hemoStrept
Tetracyclines and cephalosporins .. Less potent
Erythromycin .. Resistance coming up
Sulfa drugs = incomplete eradication
All these drugs are good for prophylaxis and less effective for eradication of strept.
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
http://funnytrivias.blogspot.com
Scarlet Red
Isnt all well read !
Japanese RED boy = kawasaki disease
Asian RED boy = scarlet fever
African RED boy = Kwashiorkar ?
Scarlet fever
Has been a major morbidity and mortality
In prepenicillin era; in epidemics
The incidence and severity decreased over years with changed streptococcal virulence in response to newer antibiotics.
Rash develops in fewer than 10% of cases of "strep throat."
incidence
Age 4-8 years peak
By the time children are 10-years-old, 80% have developed lifelong protective antibodies against streptococcal pyrogenic exotoxins.
Scarlet fever is rare in children younger than 2 years, because of the presence of maternal antiexotoxin antibodies and lack of prior sensitization.
Despite incomplete Kawasaki label
Scarlet fever is easy to diagnose..
Seen in kids not exposed often to streptococcal infections; thus not having any antibacterial or antitoxin immunity.
Diagnostic is red ..
Red tonsils red tongue and red rash !
White – red- strawberry tongue
Starts on face, nonpunctate; on trunk it is punctate erythematous boiled lobster appearance
And evidence of Hemolytic Streptococci
Other signs: falsly diagnostic
Circumoral Pallor
Pastia sign
Pin hole peeling
Differentials
If rash is illdefined with mild tonsil = Rubella
If rash is confluent = closer to measles
If exudative tonsillitis = closer to staph
Macular rash = drug rash
Tender nodes = adenitis
Nondiscrete LN = closer to diptheria
If no strept = incomplete Kawasaki
Clinical variants
Mild = ambulatory, fever is major symptom
Moderate = toxic look, with some dysphagia
Severe = bedridden
Septic Scarlet fever = local sepsis/ perf
Toxic Scarlet fever = systemic sepsis
Extrafaucial scarlet fever
complications
ENT purulent –it is, pneumonia , meningitis
Adenitis
Vulvovaginitis
R Nephritis
R Myocarditis
R Polyarthritis
Risk following an untreated streptococcal infection
Acute rheumatic fever : 3% in epidemic 0.3% in endemic scenarios
Glomerulonephritis 10-15%
Easy to treat…
Hemolytic strepts respond promptly to benzyl penicillin and Benzathine Penicillin
10 days oral penicillin
Use of any other drug indicates lack of knowledge on part of the prescriber
Why not….
Other penicillins.. Less effective for hemoStrept
Tetracyclines and cephalosporins .. Less potent
Erythromycin .. Resistance coming up
Sulfa drugs = incomplete eradication
All these drugs are good for prophylaxis and less effective for eradication of strept.
Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA
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