Conference Notes 8-16-2011

Conference Notes 8-16-2011
Cerebral edema has unclear etiology.   Higher risk in kids less than 5yo, initial presentation, severe acidemia, dehydration,  serum sodium not rising as expected. 
Easy version of giving fluids is 1.5X maintenance.  
No insulin bolus.  Give insulin at 0.1 unit/kg.  Insulin supresses glucose and ketone production.
Give K if potassium is less than 5.5 and pt has made some urine.  Give 30meq of KCL in a liter of saline. 
Na should increase by 2.4 for every 100 decrease in glucose. 
Don't worry about phos unless it falls below 1. 
No bicarb unless cardiac arrest or ph is <6.9.
 If you suspect cerebral edema developing give mannitol or 3% saline (5ml/kg)
Electrolyte abnormalities causing seizures:    hyponatremia, hypocalcemia, hypomagnesium
Bilious emesis in the first year of life : volvulus due to malrotation diagnosed with upper gi series.   needs surgery
Complications of HSP: renal involvement, intussusception, gi bleed, hypertension, pseudotorsion, joint involvement.    HSP is an IGA vasculitis. 
MANTRELS for appy: migration, anorexia, nausea/vommit, tenderness in RLQ, rebound tenderness, elevated temperature, leukocytosis, shift of wbc's to left.   Score less than 5 makes appy unlikely,  score more than 8 is highly likely.
Life threats from nephrotic syndrome are infection and thromboembolism.  They have increased levels of thrombolytic inhibitors and increased viscosity. 
Post-strep glomerulonephritis: facial edema, hematuria/proteinuria/casts, tea colored urine, htn.  Restrict fluids, na restriction, lasix. Excellent prognosis. 
Diagnosing SCFE: Use Kline's Line.  A line along the lateral aspect of the femoral neck  should intersect the epiphysis in a symetric fashion bilat. 
SALTER HARRIS FX:  physis=1, metaphysis=2, epiphysis=3, metaphysis and epiphysis=4,  impacted=5
CRITOE= Capitellum 1yo, Radial head 3 yo, Internal Epicondyle 5yo, Trochlea 7yo, Olecranon 9 yo, External Epicondyl  11yo
Cardinal features of HUS are Microangiopthic Hemolytic Anemia, Uremia and Thrombocytopenia. 
Gastric lavage only with massive ingestion in the first hour with protected airway.
Whole bowel irrigation for sustained release preparations, early presentation, pills seen on xray.  Contraindicated for hypotension and decreased bowel sounds. 
Give charcoal up to 2 hours out.   
 Give calcium,  try glucagon,  and the main thing is Insulin and glucose to increase transmembrane calcium flux.  Insulin also has a pressor/inotrope effect.  Insulin also pushes glucose into the myocyte to feed the heart.   Insulin dosing is being ramped up by toxicologists.   High dose insulin is a first line therapy for CCB OD.  Insulin dose is 1u/kg bolus and then 0.5u/kg drip.   Give 1 amp glucose push then D10/.45ns at 80% maintenance.  Keep close eye on potassium.
IV fat emulsion can also be used. It acts as a lipid sink for lipid soluable drugs like local anesthetics and calcium channel blockers.  Also feeds the myocytes and opens calcium channels in myocytes.  Lipid  emulsion can mess up lab tests like measuring potassium.
Immediate release preps can dispo home after 6 hours on a monitor.  Sustained released preps or amlodipine admit for 24 hour monitoring. 
Escalating actions are the cornerstone of NALS.   Tactile stimuli and warming> bagging with room air for 90 seconds>  bagging with oxygen> intubation>  chest compressions>   iv epi 0.01mg/kg 1:10,000 iv/io/uvc. 
If meconimum present: child vigorous no suctioning; child not vigorous suction with et tube.