Pediatrics - 2025

ACLS

• Defibrillation - 2-4J/kg (Max 10J/kg) Cardioversion - 0.5-1 J/kg
• Epinephrine Dose Cardiac Arrest: 0.01mg/kg (max 1mg) - 1:10,000
• Lidocaine: 1mg/kg
• Amiodarone: 5mg/kg
• Procainamide: 15mg/kg
• Atropine: 0.02mg/kg (max 1mg)
• Adenosine: 0.1mg/kg (max 6mg) first dose, 0.2mgkg second dose (max 12mg)
• Sizes:
• ETT >2yr - (Age/4)+3.5 (cuffed) OR diameter of pinky
• Premie: 2-3mm
• Full term: 3-3.5mm
• 1 yr: 4.0
• ETT Depth: ETTx3
• CT size: ETTx4
• Foley/OG/NG: ETTx2
• Fluids: 20cc/kg NS/LR or 10cc/kg PRBC, IV/IO
• BP: (Agex2) +70 = minimum - can be used once >1yo

Neonatal Resuscitation:

• Dry, Warm, Stimulate
• Oxygen
• Chest compressions if HR<60 despite other measures
• Intubation
• Drugs: Standard approach
• Can access umbilical vein up to 7 days after delivery

Airway:

• Large occiput, anterior larynx
• Shorter trachea → increases risk right mainstem intubation
• Miller blade
• Narrowest part of airway? Cricoid
• Needle cric? <8 yo, Surgical cric? 12
• ETT Meds: LANE → Lidocaine, Atropine, Naloxone, Epinephrine

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BRUE - Brief Resolved Unexplained Event

• Resolved event in <1 yr old, lasting <1 min including one or more of:
• Color change (central cyanosis or pallor)
• Change in breathing
• Change in tone
• Altered LOC
• No other explanation for event after evaluation

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• HIGH RISK
• Premature
• Age <60 days
• >1 Event
• CPR by trained medical provider
• ADMIT ALL

• LOW RISK
• First BRUE
• Age >60 days
• >/=32 weeks GA
• Corrected GA >45wks
• No CPR
• No concerning H/P findings
• Consider DC to home
• Consider: Pertussis testing, EKG, Brief monitoring with telemetry and serial obs

Sudden Infant Death Syndrome (SIDS)

• MCC Death 1 mo - 1 yr, Most commonly occurs btw 2-4 mo
• Unknown definitive cause - suspected hypoxia, ANS dysfunction, upper airway obstruction/rebreathing expired air → High CO2, all possible contributing factors
• Increased risk: AA, male, premature, Low birth weight/IUGR, maternal age <20, sibling with SIDS, prone sleeping, mother with drug abuse, smoker, overheating
• 5x risk - soft bedding
• 40x risk - adult bed
• 3x risk - smoking
• BACK TO SLEEP
• In Crib
• Nothing in sleeping area
• Face uncovered
• Tight mattress cover
• Pacifier
• Other protective factors: Room sharing to 1 yr & Breastfeeding
• Apnea monitors have no effect on outcomes….yet.

Inconsolable Crying

• Trauma 🡪 Hair tourniquet, Corneal abrasion, Abuse
• Infection 🡪 meningitis, AOM, UTI, AGE, diaper dermatitis, joint infxn, stomatitis
• Surgical Conditions 🡪 incarcerated hernia, testicular torsion
• GI 🡪 Volvulus, Intussusception, Anal Fissure, Foreign Body
• Intestinal Colic 🡪 MCC excessive crying
• 3+ hrs/day, 3+days/wk for 3+ weeks
• Sudden onset, paroxysmal crying, flushed face, circumoral pallor, drawing up to legs, clenched fits
• Normal work up
• *****ALWAYS LOOK UNDER THE DIAPER******

CARDIOLOGY

• Cyanotic: TA, TGA, Tricuspid atresia, TOF, TAPVR Acyanotic: ASD, VSD, COA, PDA
• Tetralogy of Fallot - VSD, RVH, Overriding aorta, Pulmonic stenosis
• PE: holosystolic murmur
• XR: Boot shaped heart EKG: RAD
• Tet Spells - hypercyanosis, exertional dyspnea, seizures, syncope → increased right to left shunt
• Tx: knee to chest, supplemental O2, morphine, phenylephrine, propranolol, ketamine
• TGA - transposed aorta/pulmonary artery - requires PDA and VSD/ASD for life. Assoc with GDM
• XR: Egg on string Tx: PGE to keep PDA open
• PDA - continuous machinery murmur, bounding pulses, PDA should close within 1st week of life
• PDA dependent lesions → COA, critical AS, hypoplastic Left heart, tricuspid atresia, TGA. Tx: PGE
• PDA closure → Indomethacin
• COA - boys>girls, Turners syndrome, intermittent claudication, asymmetric hypertension, systolic murmur that radiates to scapula, differential cyanosis, weak or absent femoral pulses
• XR: Figure of 3 sign, rib notching
• Can be delayed diagnosis. Tx if severe with PGE to keep PDA open
• TAPVR - pulmonary vein connected to SVC/coronary sinus/portal vein. PFO/ASD needed. XR: Snowman
• Ebstein’s Anomaly -- TV displaced into RV. Associated with Lithium use. Holosystolic TR murmur. Tx: PGE, Sx

CARDIOLOGY

• Congestive Heart Failure/Congenital Heart Disease:
• CP: Feeding difficulty, diaphoresis, dyspnea/sweating with feeds, tachypnea, retractions/grunting, rales/rhonchi, hepatomegaly, failure to thrive/poor wt gain, murmur
• Causes: CHD, severe anemia, dysrhythmias, sepsis, AVM (hepatic)
• Day 1: PDA 1st Week: Hypoplastic left heart
• 2 wks: COA 1 mo: Large VSD 3 mo: SVT
• 1-2 yrs: Myocarditis, Cardiomyopathy, Severe anemia, Kawasaki disease
• 10 yr: Rheumatic fever
• Tx: O2, Digoxin, Lasix, Dobutamine/Nitro prn, if associated with CHD consider PGE1
• Digoxin contraindicated in: TOF, Myocarditis, HR<100, Subaortic stenosis
• Eisenmenger’s Syndrome -- Irreversible. L → R shunt → Pulm HTN → RVH → Shunt reversal to R→ L → Cyanosis.
• Syncope -- everyone gets an EKG
• MCC: Vasovagal
• MUST RULE OUT: Brugada, HOCM, WPW, Long QTc, ARVD, Arrhythmia
• Consider metabolic, neurologic (seizure), orthostatic, toxicologic causes

PULMONARY

• Pneumonia:
• Neonates: GBS, E coli, Listeria → Tx: Amp+Gent/Cefotaxime
• Admit <3 mo, Consider Erythromycin for afebrile pna to cover Chlamydia and/or Pertussis
• Toddler-Teens: Viral, S. PNA, Atypicals (Chlamydia/Mycoplasma), H flu
• Viral: RSV, Adenovirus, Parainfluenza, Influenza
• Chlamydia - Staccato cough, Conjunctivitis, Afebrile, Eosinophils
• CXR: Hyperinflation with increased interstitial markings.
• Tx: Oral Erythromycin or Bactrim
• S PNA - lobar pna, fever, tachypnea
• Tx: Ceftriaxone/Cefotaxime + Azithro
• Outpatient - Amoxicillin or Augmentin +/- Azithro, Consider Doxy if >8yo
• Pertussis - GN coccobacillus, paroxysms cough/cyanosis, post-tussive emesis, rectal prolapse, diaphragm rupture, rib fracture, adult reservoir (or anti-vax). High WBC
• Catarrhal - URI symptoms lasting >2 weeks (most infectious)
• Paroxysmal - coughing spasms and whoop (inspiratory stridor), post-tussive emesis
• Recovery - improvement with mild cough x months
• Tx: Vaccination, Azithromycin/Erythromycin
• Chemoprophylaxis for household contacts - Azithromycin

PULMONARY

• Bronchiolitis - RSV (flu, parainfluenza), 2-6mo, spring/winter
• Submucosal edema/Mucus plugging → airway narrowing → wheezing/stridor
• Wheezing, dyspnea, tachypnea, low grade temp, retracting/grunting
• Can be associated with apnea <3 months - Consider admission
• Tx: isolation, humidified O2, rehydrate, Nasal suction, hypertonic NaCl neb,nebulized Epi, heliox, BiPap
• Ribavirin (Palivizumab) in high risk.
• New vaccination initiative - elder adults and pregnant women in 3rd tri
• Admit: Inability to tolerate PO, hypoxia, premature, severe resp distress, apnea, <2mo
• Cystic Fibrosis - AR, MCC lethal genetic disorder whites. Abnormal exocrine glands → thick, sticky mucous, salty sweat, usually Dx by 1 yr.
• Meconium ileus, Recurrent respiratory infections, pancreatic exocrine deficiency
• Colonized with pseudomonas by age 12.
• Dx: high sweat chloride , hypochloremic alkalosis
• Tx: antibiotics, supportive care, ultimately lung/pancreas transplant
• Cx: Cor pulmonale, hemoptysis, PTX, intussusception, electrolyte depletion

GASTROINTESTINAL

• Inborn Error of Metabolism: Hypoglycemia + Metabolic Acidosis + Dehydration +/- AMS
• Labs: Acidosis, Ketosis, Hypoglycemia, Lactic acidosis, Hyperammonemia
• Tx: NPO, Bicarb, Fluids, Glucose
• Pyloric Stenosis: first born, 2-6 mo, “palpable olive”, peristaltic wave, projectile non bilious vomiting with hypochloremic, hypokalemic, metabolic alkalosis, kid appears hungry
• Dx: US Tx: Surgery - Pyloromyotomy
• Malrotation of Gut: abn mesenteric fixation with twisting of bowel. Within first 30 days, Bilious vomiting, palpable mass
• Dx: Double Bubble on XR, Upper GI - apple core/cork screw. Tx: NGT. Fluids, Abx, Surgery
• Intussusception: 3mo-6yr, MCC ileocolic/ileocecal, colicky abdominal pain, legs drawn into chest, vomiting, currant jelly stools (late), sausage shaped vertically oriented mass in right abdomen, HSP/Meckels/Erythromycin. +/- lead point
• Dx/Tx: Air enema Dx only: US - target sign/bulls eye/coiled spring sign
• DDx Bloody Stools: Allergic Colitis, Anal Fissure, Secondary Lactase deficiency, Intussusception, NEC, Swallowed maternal blood, infectious AGE, Meckel’s diverticulum
• Neonatal Jaundice: Tx: IV hydration, Phototherapy + Riboflavin (B2), Exchange transfusion if Bili>20
• Physiologic - day 2-4, peaks ~7 days, Bili <10, hemolysis of fetal RBC d/t decreased glucuronyl transferase
• Breast Milk - glucuronyl transferase inhibitors in breast milk, peaks by 21 days
• Tx: self-resolves, cessation of breast feeding only if Bili >20
• Breastfeeding Failure- insufficient intake, dec BM → inc Bili, 1st week of life, Increase feeds/Supplement
• Can lead to kernicterus
• Pathologic - any jaundice in 24 hours, direct hyperbilirubinemia, evidence of kernicterus

GASTROINTESTINAL

• Congenital Diaphragmatic Hernia → Bochdalek (Left, MCC), Morgagni (Right)
• Assoc Anomalies: CHD, GI, GU, cystic kidneys
• CP: respiratory distress, vomiting. PE: scaphoid abdomen, bowel sounds over chest
• CXR: hypoplastic lungs, air-filled loops bowel in chest Tx: OGT, hydration, surgery, +/- ETT
• Tracheoesophageal Fistula → Premature. Proximal esophageal pouch, Fistula between trachea and distal esophagus. Associated polyhydramnios.
• CP: increased oral secretions, choking/coughing with feeding attempts, recurrent aspiration PNA
• Dx: Inability to pass NGT/OGT Tx: Surgery
• Omphalocele (defect umbilical ring, intestines covered in sac, associated anomalies) VS Gastroschisis (defect abdominal wall, evisceration without sac)
• Keep warm, Place NGT/OGT to decompress gut, cover intestines with saline-soaked gauze and place in bag, IVF resuscitation, Antibiotics, Surgery
• Incarcerated Hernia - 1yr, vomiting/irritability with scrotal or inguinal mass
• Tx: Manual reduction, if unsuccessful surgical consult

Necrotizing Enterocolitis

• Most common GI emergency in neonates. 25% mortality. Prematurity/Low Birth Wt
• First 2 weeks of life
• Ischemia/Necrosis of intestines with sloughing of intestinal lining
• CP: Feeding intolerance, bilious emesis, abdominal distention, bloody stools (late), respiratory distress, septic shock, abdominal wall erythema
• XR: pneumatosis intestinalis, portal vein gas, bowel wall edema, loss of colonic haustra, dilated bowel, Air-fluid levels
• Tx: NGT, IVF, Antibiotics, Surgery

NEUROLOGY - Seizures

• Febrile Seizures - 6mo-6 yr, associated with fever (rate of rise)
• Simple – brief (<5min), generalized, minimal post-ictal phase, resolves without treatment
• ID source, Give antipyretics, Can DC after observation period
• Complex - >15 min, recurs within 24 hours, focal, <6mo or >6 yr
• Needs full septic work-up, CT head, +/- LP (abn exam, incomplete Vx, recent Abx, <1yo)
• Also consider work up if seizure after day 2 of illness or currently on antibiotics
• Electrolytes: Hyponatremia, Hypocalcemia, Hypomagnesemia, Hypoglycemia
• Hypoxic-Ischemic Encephalopathy (MCC NN)
• Hydrocephalus - congenital or acquired (meningitis/tumor). Tx: Shunt
• Increased ICP -- HA,vomiting, irritability, CN VI palpsy, papilledema, “Cracked pot” , Big ventricles on CT
• Absence seizures - brief 5-10s starting spells/blinking, slow spike/wave on EEG. Tx: Ethosuximide
• Lennox-Gaustaut - 2-6 yo, frequent/varied seizures + developmental delay. Difficult to treat.
• West Syndrome (Infantile Spasms) - 3-9mo, frequent severe spasms lasting only seconds, associated with flexion/extension of head/trunk, can be single or in groups. Developmental regression
• EEG: Hypsarrhythmia. Tx: ACTH, Prednisone
• Infections (TORCH)
• Toxins
• Trauma/Abuse

Treatment: Phenobarbital (NN), Phenytoin, BZ.

• Consider Pyridoxine if refractory

NEUROLOGY - VP SHUNT

• Shunts → ventricular catheter, pumping chamber, 1 wave flow valve, distal tubing in peritoneal cavity
• Dx: Shunt series + CT
• Obstruction: MCC
• Presents with increased ICP
• Kinking, thrombosis, disconnection, migration, infection
• Distal: can’t compress reservoir
• Tap shunt (Arrest, Comatose, Clinical Deterioration)
• Proximal or Overdrainage - reservoir won’t refill
• Slit Ventricle Syndrome: chronic overdrainage for CSF → collapse of ventricles and transient obstruction
• Episodic minor HA with brief asymptomatic periods
• Trendelenburg position relieves symptoms
• Infections: within 6 months (MC within 2 weeks)
• S. epidermidis, S. aureus
• Culture will be positive, Tap likely negative
• CP: Fever, N/V, Meningismus, Subtle behavior changes
• Tx: Vancomycin, Ceftazidime

NEUROLOGY - Meningitis

• Neonates → GBS, E coli, Listeria
• Tx: Amp + Gent + Steroids
• >2 months → S. PNA, Neisseria, H. flu
• S. PNA - highest mortality
• Tx: Steroids + Rocephin + Vanco
• Chemoprophylaxis of close contacts → Ciprofloxacin 500mg once, Rifampin 600mg BID x 2 days, Azithromycin 500mg once
• CP: irritability, poor feeding, poor suck, low tone, fever, inconsolable, bulging fontanelle, nuchal rigidity, vomiting
• Dx: LP
• CT head before LP: immunocompromised, Seizure, Abnormal neuro exam
• DON’T DELAY ABX FOR LP, start within 30 min clinical suspicion
• Bacterial CSF -- LOW glucose, HIGH opening mmhg, protein, HIGH PMN, POSITIVE Gm Stain
• Viral CSF -- normal/high Protein, mmHg, glucose, HIGH LYMPH, negative gm stain

FEVER

• <28 days - full septic workup → CBC, UA, Cultures, LP + CXR
• Antibiotics and Admit
• Highest risk for serious occult bacterial infection
• 28 days-2 months – septic work-up +/- LP and individualized disposition plan based on presentation
• >3 months -- Basic labs/cultures
• No LP if: appears well, behaving normally, CBC normal, Follow up in 24 hours, No antibiotics
• Occult bacteremia = fever + positive blood culture in well-appearing child
• MCC: S. pna, N. meningitidis, H. flu, S. aureus, GAS
• Usually 3-36 months at risk.
• Risk increased if: WBC>15k, Temp>102.2, bands >1500
• Fever + WBC <5k also high risk for serious disease - esp meningococcemia
• Tx of Fever:
• APAP 15mg/kg Q4-6 hr not to exceed 75mg/kg/day (or 3000mg)
• Ibuprofen 10mg/kg Q6-8 hr
• Avoid ASA d/t Reye’s Syndrome

INFECTIOUS

• Epiglottis → 2-6 yr old. H. flu B (less common with Vx), GABHS, S. aurues
• CP: fever + sore throat, sniffing position, neck held in extension, toxic/apprehensive, drooling, difficulty swallowing, stridor
• XR: thumbprint sign on XR
• Tx: Don’t disturb. Humidified O2. Intubate in OR (cherry red epiglottis)
• Rocephin, Unasyn, Cefotaxime
• Croup - parainfluenza, 6mo-6yr, barking seal like cough, fever, URI symptoms, worse at night
• Subglottic narrowing → stridor
• Dx: clinical, Steeple Sign on XR
• Tx: Steroids, O2, Racemic epi, Heliox
• Admit: stridor at rest, unable to tolerate PO, incomplete response to racemic Epi
• Bacterial Tracheitis - < 3yr. High fever + Stridor + Toxic + Recent viral croup
• S. aureus, S. PNA.
• XR: Shaggy tracheal border
• Tx: O2, ETT in OR → pseudomembranes/purulent secretions, Antibiotics
• Retropharyngeal Abscess - 6 mo-6 yr. Toxic child. S. aureus, GAS, Anaerobes.
• CP: Fever, ST, drooling, neck stiffness
• XR: Inspiration/Slight Extension, Widened retropharyngeal space (C2=6mm, C6=22mm)
• Tx: Rocephin + Flagyl or Clinda + Gent, ENT/Surgery consult → OR

• Post infectious GN: w/n 1-2 wks post infection, type 3 immune complex
• Strep pharyngitis or strep skin infection (doesn't cause rheumatic fever)
• Proteinuria, hematuria, hypertension
• IGA nephropathy: MC cause of GN worldwide, occurs w/n days of URI, only GN sx’s (unlike HSP)

HUS - Hemolytic Uremic Syndrome

• MCC acute renal failure in kids
• MAHA + Renal Failure + Thrombocytopenia.
• Associated with E coli 0157:H7, Shigella
• Bloody stools + Fever
• CP: Lethargy, poor UO, risk of seizure/htn, +/- bloody diarrhea
• Dx:
• Schistocytes (helmet cells), Low Hb
• Normal Coags
• Low platelets
• Uremia, Hematuria, Proteinuria
• Tx: Supportive

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GENITOURINARY

• Urinary Tract Infection
• Etiology: E coli
• CP:
• Neonates - fever, irritability, vomiting, poor feeding
• 50% children <1yr with UTI have Vesicoureteral reflux
• Child - fever, abdominal pain, dysuria, incontinence, enuresis
• Dx: Cath UA (>10 WBC = pyruia, suggestive of UTI), Bacteriruia is more reliable with >100k cfu, positive nitrites, culture confirms infection
• Who gets a culture? Female <3, Male <1 or Any Uncircumcised
• Tx: Amoxicillin, TMP-SMX, Keflex
• Males:
• Phimosis → foreskin cannot be retracted
• Tx: steroids, dorsal slit 🡪 circ
• Paraphimosis → foreskin swollen/retracted
• Call the paramedics
• Tx: gentle pressure, dorsal slit 🡪 circ
• Balanitis/Balanoposthitis -- check glucose, hygiene
• Testicular torsion - salvage rate 80-100% within 6 hours. Scrotal/Abdominal pain. Dx: US Tx: Sx

ORTHOPEDICS

• LIMP:
• Septic vs Transient synovitis (Kocher’s) → fever + limp
• SCFE - Obese, AA, Teens, Insidious, Displacement of proximal femoral epiphysis on metaphysis (ice cream scoop), 25-50% bilateral
• Dx: Frog leg films
• Tx: NWB, ortho, admit
• LCP - AVN, 2-12 yo, bilateral in approximately 10%, Tx: NWB, refer to ortho
• DDH –<6 mo, subtle dysplasia to dislocation. Breech Females. Hip instability, unequal leg length, asymmetric skin folds.
• Dx: Ortolani and Barlow Tx: Pavlik Harness if early, Sx if late dx
• Nursemaid- Radial head subluxation, Tx: supinate+flex, hyperpronate
• SALTER- 1 straight, 2 above, 3 lower, 4 through, 5 erase → 3-5= surgery
• CRITOE= 1,3,5,7,9,11= Capitellum, Radial head, Internal (medial) Epicondyle, Trochlea, Olecranon, External (lateral) Epicondyle
• Torus/Buckle → unilateral bulging cortex
• Greenstick → unilateral cracked cortex

ETHICS

• Consent for Treating Minors – 911, Stated protected Right, Emancipated
• State protected right to treatment: Child abuse, Pregnancy, STI, Substance abuse
• State-defined emancipation: Married, Military, Self-supporting
• Jehovah’s Witness: If LIFE THREATENING - you can treat without parental support
• Otherwise must go through ethics committee/court
• Child Abuse - failure to thrive, Avoids eye contact, difficult to console, inadequate body weight, poor hygiene, multiple injuries with inconsistent histories, seeking medical attention delayed, bruises over multiple areas
• Nonaccidental trauma: any fractures <6mo, spiral fractures, chip/corner fractures, bucket-handle fracture, posterior rib fractures, cigarette burns, immersion burns, linear skull fx
• Dx: skeletal survey
• Tx: CPS, Admit

GRAB BAG

• Weird genitalia and low Sodium: Congenital Adrenal Hyperplasia 21-hydroxylase
• Elevated ACTH, female virilization
• Can present in acute adrenal crisis (low Na, HyperK, Hypoglu, AGMA)
• Tx: Steroids
• No fleets enemas in infants (hypertonic phosphate 🡪 hypercalcemia)
• Meckel’s Rule of 2s: 2:1 M:F, w/in 2ft ileocecal valve, 2inches in length, 2 types of tissue (gastric, pancreatic), symptomatic by 2 yo
• Painless BRBPR
• Fluids: 4:2:1 rule for MIVF/hr
• Oral rehydration best unless severe dehydration 🡪 full age appropriate diet after rehydration
• Dehydration: Mild (3% - 50ml/kg deficit), Mod (6-9% - 100ml/kg), Sev (9% - 150ml/kg)
• JIA: risk for cervical instability, salmon colored patchy rash, joint pain, fevers
• Kawasaki's: #1 cause acquired heart disease in peds
• JONES: joints, pancarditis, nodules, erythema marginatum, sydenham choea 🡪 Rheumatic
• Stridor without obvious etiology? Look for hemangiomas
• Variation in pattern of stridor 🡪 consider FB
• First line Tx AOM? High dose Amoxicillin 90mg/kg/day
• Hirschsprung? Empty rectal vault, meconium ileus, blow out sign
• Males>Females
• Delayed passage of meconium, distension, chronic constipation
• Dx: Barium enema – cone shaped transition zone with dilated proximal colon
• Cx: Toxic megacolon Tx: Sx
• Bradycardia in NN almost always due to hypoxia
• Strep throat can cause abdominal pain in kids >3 yo