This page is meant mainly for clinical tips.. pediatric medicine tips and tricks

http://drpeds.blogspot.com

http://funnytrivias.blogspot.com

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Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA



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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.

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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)

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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


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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.

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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!!!
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17/05/2003
what are the four commonest causes of excessive crying?:

TIP:Its natural!! 1. hunger, 2. URTI 3.earache 4.colic;

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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)

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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.

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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

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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?


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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?

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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.

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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)



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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.

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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.

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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.

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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.

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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


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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.

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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).

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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.


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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.

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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.


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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