Download - Some Algorithms in Pediatrics
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Consulting Child Specialist
Neonatal Intensivist
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Algorithm: Child with bleeding
Hx, PE
PT,APTT Platelets Bleeding Time
Evaluatecount &function
EvaluateBT
Considerrepeatevaluationfor VWD
Platelet aggregationstudies (ADP,collagen,
ristocetin, epi,arachidonic acid)
Thrombin clotting time(TCT)
VWF functionAntigen cofactor
Mixing
studies1:1 Pt.:pooledplasma
Contaminn
withheparin orthrobolytic
agent
N (or
ristocetin abN)
Glanzmann thrombo
Drug effect (aspirin)
Storage pool def.
Specificfactorinhibitor
APLsyndrome
Specificfactor
assays
8,9,3, vit.k,
Isolated
factorsVWD
Fibrinogen
Normal Abnormal
Bernard Soulier
Uremia
VWD
Confirm with:
Multimer analysis
Family studies FDP Consider
Dys/A/Hyp
fibrinogrenDIC
N AbN
N AbN
N AbN N
AbN
AbN
Not corrected Corrected - ve
N AbN
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Approach for isolated thrombocytopenia
Hx, PE, CBC Differential Dx, PS, Platelets
Assess platelet morphology
Assess forsplenomegaly or
lymphadenopathy
Bernard-Soulier
Wiscott-Aldrich
May-Hegglin anomaly
Glanzman thromboaGray platelet syndrome
Bone Marrowaspirate
Normal Examination CongenitalAnomalies
Malignancy
Infection HIV
Storage disease
Hypersplenism
ITP
Viral inducedDrug inducedHIVCollagen vascular
InfantHemangiomaAplastic anemia,Fanconi anemiaFamilial
Skeletal
Fanconi anemia
TAR
Cyanotic CHD
Eczema
Wiscott-Aldrich
Hemangiomas
Kassabach-Merritt
Abnormal
Positive
Negative
Normal
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Diagnostic algorithm of hypoxia & hypercarbia
Hypoxemia, Hypercarbia
Respiratory effort? (respiratory distress)Yes No
Mechanical dysfunction of lungsor chest wall
Anatomy of respiratory drive or
respiratory muscle function:
Drug induced
(Opioids,barbiturates)
Brain stem injuryPolyneuritis
Myopathy
Tachypnes
Lung volumeRales & cracles
Prolonged insp
Or expi
Airway noises
Restrictive ds
Croup, FB
Epiglottitis
Obstructive ds
Stridor
Long inspi
Wheeze
Long expi, lung vol
Extra-thoracicObstruction
Croup
EpiglottitisForeign Body
Intra-thoracic
Obstruction
Asthma
BronchiolitisTracheo-bronchomalacia, FB
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Guide to initial Mm of febrile neutropenic patient
Fever (>380C) & neutropenia (
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Pathway for detection & referral of DDH in newborn
PE in newborn infant
Unstable Uncertain Stable
Reassessin 2 weeks
No riskfactors
Riskfactors,breech,
family Hx
Abnormalexam
Normalexam
Periodicfollow-up
US 3 mo
or
XR 6 mo
Abnormal exam Normal exam
Refer toPediatric
Orthopedist
Continueperiodic
follow-upuntil after
ambulation
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Evaluation & Tx of Urinary Incontinence in children
Hx, PE Urinalysis
Nocturnal Enuresis Day & Night Incontinence
Maturation delay Continuous Intermittent
Age 5 yrs Dysfunctional
VoiderEnuretic alarm,Biofeedback,
DrugsNo Tx IVP/VCUG Anticholinergics,
Time voiding,Biofeedback
Refractory Child
>10 yrs age Ectopic Ureter(female)
Normal
Ultrasound
Abnormal Surgery Urodynamics
VCUGUrod namics
Normal NeuropathicBladder
DysfunctionalVoider
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Approach to IEM causing chronic encephalopathy
Chronic Encephalopathy
Abnormalities outside the CNS?
Mainly graymatter
Seizures
Blindness
Dementia
Mainly white matter
Spasticity
Weakness
Ataxia
Muscle Skin/connectivetissue
RES
CNS only CNS & PNS
Mitochondrial(eg, CRSM syn.,Leigh ds,MELAS, Alperssyn)
Lysosomalstorage(eg, NCL, GM2)
OtherB6 dependency
Amino acidds
Organicacid ds
Lysosomalds(eg, GM1 late)
Peoxismalds
OtherCanavan
Alexander
Lysosomalstorage(eg, MLD, GLD)
Peroxismal
ds(eg, NALD, IRS)
Mitochondrial(myopathies)
Amino acidds(eg, homocyst)
Lysosomal
storage(eg,Mucolipidoses,MSD)
Dysmorphicsyndrome(eg, Menkes)
Lysosomalstorage(eg, MPS,Gaucher,NPD, GM1,
Sialosis)Peroxismalds(eg,Zellweger)
YesNo
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Approach to IEM a/w metabolic acidosis
Metabolic Acidosis
What is the anion gap?
Normal Elevated
Renal HCO3-losses
Accumulation of fixed anion
Carbohydrate ds(eg, galactosemia)
Lysosomal storage(eg, cystinosis)
Amino acid ds(eg, hepatorenal tyrosenemia)
Mitochondrial
Urinaryorganic acids
Plasmaketones
Plasmalactate &pyruvate
Organic acid
ds(eg, propionicacidemia,methylmalonicacidemia)
Organic acid
ds(eg, 3-ketothilasedef., SCOT def, 20finding in other OAdiseases)
Oxphos ds /pyruvateoxidation (eg,PDH def., PC def.)
Organic acidds (eg, MCD)
Carbohydrateds (20 finding indisorders ofgluconeogenesis)
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DDx of IEM a/w severe hypoglycemia
Hypoglycemia
Nonglucose-reducing substance in urine
Positive Negative
Carbo. Ds(eg, galactosemia,HFI)
Amino acid ds(eg, hepatorenaltyrosenemia)
Ketones Plasma aminoacids, NH3,
urine organicacids
Organic acidds(eg, propionicacidemia)
Amino acid ds(eg, MSUD)
Low High
Plasma FFA Hepatomegaly
High Low Present Absent
FAO ds
(eg, MCADdef)
Consider:
Hyperinsulism
Plasma lactate Plasma hGH,
cortisol, T4
High Normal Appropriate Abnormal
Carbo. Ds
(eg, GSDI,
FDPase def)
Consider:
Ketotic
hypoglycemia
Consider:
Ketotic
hypoglycemia
Consider:
Endocrinopathy
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DDx of inborn errors of ureagenesis
Inborn Errors of Ureagenesis
Measure plasma citrulline
Absent/
trace
N/ Moderate
Marked
Urinary orotic acid Plasma arginine ASA in
plasma &urine
Normal Elevated Low/N Elevated
CPS 1 def
NAGS def
OTC def Argininemia Argininosucconoc
aciduria
Citrullinemia
Urinarylysine,ornithine,arginine
Plasmaornithine,urinaryhomocitr
ulline
LPI HHH
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Approach to child with disproportionate short stature
Infant with disproportionate short stature
Examine segments
Short limb Short trunk
Rhizomelic Mesomelic Acromelic
Associated
findings
Associated
findings
Associated
findings
Associated
findingsSkeletalsurvey
Skeletalsurvey
Skeletalsurvey
Skeletalsurvey
Define X-raypattern
Spondylo/epiphyseal/diaphyseal
Define diagnostic possibilities
Make Dx
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Approach to child with microcephaly
Child with microcephaly
Prenatal onset Postnatal onset
Measureparents
Do
ophthalmo
Small forgestational
age
Eye findings Minoranomalies
Seizures /neurological
signs
Multiplecontractures
d/tdeformities
Considerappropriatesyndromes
Do karyotype/ophthalmo
Dobiochemical
studies;CT/MRI/EEG
Considersyndromes
Signs of IUI
Doconfirmatorystudies
No diagnosis
Do CT/MRI
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Treatment of Acute Severe Asthma
Airway, Oxygen, IV Fluids+ for Dehydration, Cardioscope
Inj. Hydrocortisone 10 mg/kg stat then 2.5-5 mg/kg/dose q6hInj. Methylpred 1-2 mg/kg q6h, IV/IM Dex 1-2 mg/kg q6h
Salbuta/Levo nebulization q20 min 3 or
Ipratropium neb. Q20 min 3, then q6h for 24-48 hrs