Wednesday Lecture Notes, 9/3/2014 (Irritable Child) [EDITED 9/9/2014]

EDITED 9/9/2014 with additional note on NMS vs. Seratonin Syndrome

1230 – Jr/Sr Session (Cantor)

Rabies manifestation ascending paralysis (anterior horn neuron)

Botulism dt honey, home canning, motor paralysis.  Adult gut flora suppresses toxin dt normal flora & pH.

Erythroderma ~Staph or Strep dt erythrogenic toxin relase & slough c streptokinase…

Ornithine transcarbamylase deficiency ~ hyperammonemia (urea cycle) & lethargy

“sleepy kids get sugars”

HSV encephalitis will have temporal & liver involvements, CSF blood & whites… should CT first.

Myasthenia Gravis ~ edrophonium chloride (acetylcholinesterase inhibitor sp autoimmune synapse degradation) …like physostigmine for anticholinergic  tox.

JONES criteria for Rheumatic Fever (Joints, Heart, Erythroderma, Sydenham)

Dialyzable drugs…

Radioopaque ingestions include Fe. Pneumonic (“COINS” ~ chloral hydrate & cocaine, opiate packets, Iron & metals, Neuroleptic agents, Sustained Release capsules/Salicylates)

Toxic alcohols Methanol, Ethylene Glycol, Isopropyl

NMS Red Hot & Rigid (antipsychotics) v Serotonin Red Hot & Flaccid (SSRI), benzos!

[EDIT: NMS is classic lead pipe rigidity; Serotonin toxicity is classically described as lower extremity hyperreflexia/clonus which can have rigidity. The main helpful differentiators is: the causative agent; the onset and duration of effects]

“caine” anesthetics ~ Methemoglobinemia

Theophylline ~ hypokalemia (Aldosterone causes Na up, K down) ~ Albuterol or black licorice

Clarithromycin & Aminoglycosides affect Tegretol (carbamazepine) metabolism!

Windshield washer fluid… Fomepizole.

6yo Leg Calve Perthes avascular necrosis “dead head” from medial circumflex femoral aa.

Afebrile irritability in 3wk old babies, think: corneal abrasion, hair tourniquet, torsion, uti, rib frx.

…fluorescein & tetracaine!

Apt test is for infant hematemesis to determine fetal v maternal blood.

Sepsis in neonate from UTI/ecoli most common.

3wks old in heart failure… VSD.  PDA dependent… (NSAIDs close, PrOstaglandins Open)

Aberrant L coronary (ALCAPA) ~ infant STEMI (L coronary off Pulm aa rather than Ao)

5Ts Truncus, Transposition, Tricuspid Atresia, Tetralogy, Total Anomolous Venous return

130p – Congenital Metabolic (Cantor), Tox (Cantor)

3yo Sz febrile… simple? can be… but pupils dilated, hypertense, SWEATY.

OTIS CAMPBELL mnemonic for Sz. <;

Caladryl can cause benadryl toxicity.

Cholinomimetics can cause severe toxicity (~bug bombs, organophosphates) ~SLUDGE mnemonic. …atropine & pralidoxime.

MUDPILES for anion gap…<;

toxic alcohols CAN be tested in house.


230 – Limp (Barus)

Keep an open mind… pain in lower extremity often refers.

Dicrocoeliumdendriticum … ANT ZOMBIES <;, <;.  ~Rabies…

Gradual exam, make the kid try to move!

Ask mom where the pain is. “Mom knows best” [when she cares to].

FABER test (flex, abduct, & external rotation) ~ SI joint pathology.

Septic Hip Rules (Kocher 1999, 2004 commonly cited).

Galeazzi test for dislocation, Ortellani/Barlow test at birth…

Trendelenburg gait… fast side is the good side, gluteus medius weakness.

Antalgic (foot drag) gait represents offloading…

“Stooped” Gait, Hip flexor or abdominal pathology.

Hip circumduction ~ antalgic.

Ataxic Gait (vestibular, ~drunk…)

Foot Drop  “marching” or “foot slap” gait, “steppage”.

Toddler’s fracture, won’t walk, “toe pain”.

SCFE ~Klein’s Lines.

JRA can cause severe disability & deformity.

Radial Head reduction ~ supination & flexion, feel for click, squeeze radial head.

Osteosarcoma osteoclastic c cortical elevation.

Maisonneuve Frx c ankles, check the calf!

Osteomyelitis c periosteal elevation.

Child femur frx ~ almost always call CPS!

Calcaneal Frx ~ Bohler’s Angle (20* to 40*) associated c lumbar burst frx!

Candy works for attention! (…even on adults.)


3p – SIDS v SUDI… (Thabet) & Congenital Metabolic Disorders…

<1yr of age, 2200 cases in 2005.  Leading cause of death 1 to 12 months.

Most common @ 2 to 4 months (highest risk), starting to develop head movements.

Males > Female.  Sleep positioning important.   Unaccustomed prone positioning worse.

supervised “tummy time” is ok only with active parental observation, but otherwise “back to sleep”!  Cosleeping with siblings or parents

Pacifier use found to be protective?

Minimize blankets & stuffed animals!

…*Congenital Metabolic: Sugars? Fats? Proteins? …go down the line…

Ketosis? Lactic Acidosis? Fatty Acid Problems…

Ammonia? Blood Sugar! Check Lactate & Pyruvate, LFTs, Uric Acid, UA!

Galactosemia cannot break down milk sugars…

Glycogen Storage: vonGierke, Pompe, Cori, Anderson, McArdle…

Newborn screen for PTU, proprionic acid, melonic acid… takes 1 to 2 weeks for newborn screen to process.

Can present c ALTE or SIDS!

MCAD deficiency do poorly c fasting…

Resp Alkalosis, consider Ammonia.

Met Acidosis broader DDx, usually high anion gap. (Consider Lactate/Pyruvate ratio…)


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