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I.
RESPIRATORY SYSTEM
A. ACUTE BRONCHITIS
DEFINITION
Acute bronchitis is infection and inflammation of the bronchi. It is a common disease that can
occur at any time of the year, but most cases happen in the winter months. It is most common in
infants and young children.
CAUSES & RISK FACTORS
Acute bronchitis is the result of a viral( e.g. Respiratory syncitial virus) or bacterial infection
(e.g. Hemophilus influenza) which causes inflammation of the airways; bronchi. Mycaplasma
pneumoniae is a common cause in children older than 6 years.
Risk factors:
- Air pollution exposition
- Lung irritants
- exposition to cold
SIGNS & SYMPTOMS
Painful cough : Dry cough in early stages and productive cough (with purulent sputum)
usually in later stages (in 2 to 3 days).
Children younger than 5 years rarely expectorate, sputum is usually seen in vomitus (i.e.
posttussive emesis)
Wheezing
Generally sick
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DIAGNOSIS
- Making a diagnosis of acute bronchitis begins with taking a thorough medical history,
including symptoms, and exposure to lung irritants.
- A physical examination is also performed and includes listening with a stethoscope to the
sounds that lungs make during respiration. Lung sounds that may point to a diagnosis of acute
bronchitis include wheezing, or crackling sound and decreased lung sounds.
- A chest X-ray and CT scan of the chest can help to exclude the diagnosis of pneumonia.
- Blood or sputum culture if antibiotic therapy is under consideration
DIFFERENTIAL DIAGNOSIS
Differential diagnosis include but are not limited to:
- Pneumonia
- Upper respiratory tract infections such as rhinitis
- influenza or cold flu
TREATMENT
- The goal of treatment of acute bronchitis is to control symptoms, such as fever, cough, and
shortness of breath, and to minimize the development of serious complications, such as
pneumonia.
The first step in treatment is prevention. The risk of developing acute bronchitis can be reduced
by avoiding air pollutants, cold
- Ensure that the child has adequate oxygenation.
- General measures include:
Rest
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Bronchopneumonia
B. PNEUMONIA
Pneumonia, inflammation of the pulmonary parenchyma, is common throughout childhood but
occurs more frequently in infancy and early childhood. Clinically, pneumonia may occur either
as a primary disease or as a complication of some illness.
Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an
estimated 1.2 million children under the age of five years, accounting for 18% of all deaths of
children under five years old worldwide (WHO, 2012)
Morphologically, pneumonias are recognized as follows:
Lobar pneumonia: all or a large segment of one or more pulmonary lobes is involved.
When both lungs are affected, it is known as bilateral or double pneumonia.
Intertitial pneumonia: The inflammatory process is more or less confined within the
alveolar walls (interstitium) and the peribronchial and interlobular tissues.
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CAUSES
Viral: respiratory syncytial virus is the most common viral cause of pneumonia.
Atypical (mycoplasma)
In HIV- infected infants, Pneumocystis jiroveci is responsible for at least one quarter of
all pneumonia deaths.
RISK FACTORS
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-The final phase, resolution, the macrophage is the dominant cell type in the alveolar space,
and the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory
response.
This pattern has been described best for pneumococcal pneumonia and may not apply to
pneumonias of all etiologies, especially viral or Pneumocystis pneumoni
CLINICAL MANIFESTATIONS
Fever, chills
Tachypnea: the absence of tachypnea is a strong indication that the child does not have
pneumonia
In severe cases there is the use of accessory muscles, retractions including sub-costal and
inter-costal, sub-xyphoid, nasal flaring
Prostration. Very severely ill infants may be unable to feed or drink and may also
experience unconsciousness, hypothermia and convulsions.
DIAGNOSTIC
The clinical manifestations and the physical examination can make a diagnosis of
Pneumonia.
Blood culture especially in severe pneumonia and in infants under 3 months of age.
Gram stain and culture on respiration secretions (sputum, bronchoalveolar lavage, pleural
fluids) can be helpful
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MANAGEMENT
-
Hospitalization: its indication includes Oxygen requirement (sat. < 95%), infants < 2 months,
presence of moderate to large pleural effusions and in other very severe cases.
Antibiotics in inpatient:
. Ampicilline + Gentamycine for neonates 0-30 days
. Cefotaxin is antibiotic of choice in children between 1 month and 5 years
. If Chlamydia trachomatis or Brodetera pertussis are suspected, give a Macrolide e.g.
Erythromycine
. For Hospitalized children over 5 years: Cefotaxin+ Erythromycin
The duration of therapy depends on the patients response but in general is 10-14 days for
children up to 3 months of age and 7-10 days for children older than 3 months.
For outpatient:
. Children under 5 years: Amoxycillin in High dose (80-90mg/kg/day)
. If the child is vomiting, an initial parental dose of Ceftriaxone is given
. For children over 5 years, give a macrolide (Erythromycin)
PREVENTION
- Preventing pneumonia in children is an essential component of a strategy to reduce child
mortality. Immunization against Hib, pneumococcus, measles and whooping cough (pertussis) is
the most effective way to prevent pneumonia.
- Adequate nutrition: starting with exclusive breastfeeding for the first six months of life.
- Prevent environmental factors
- In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk
of contracting pneumonia.
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C. BRONCHIAL ASTHMA
Asthma is the most common chronic disorder in children and adolescents. About 5 million of
children under 18 years have asthma. This includes an estimated 1.3 million children under the
age of 5 years.
PATHOPHYSIOLOGY
Asthma is a chronic inflammatory disorder of airway in which many cells play a role, including
mast cells and eosinophils. The symptoms are associated with airway obstruction
(bronchoconstriction) due to inflammation with mucosal edema leading to bronchospasm. The
airway narrowing is often reversible either spontaneously or with treatment, and causes an
associated increase in airway responsiveness to variety of stimuli as well as bronchial
hypersecresion.
Risk factors
Previous allergic reactions: food allergies, allergic rhinitis, allergic sinusitis, eczema
Triggers
The asthma triggers vary from child to child and can include:
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CLINICAL FEATURES
Cough
Wheezing
Shortness of breath
chest tightness
THERAPY
-
Assess the severity: intermittent, mild persistent, moderate persistent, severe persistent.
Pharmacological management: the use of agents to control and agents for quick relief of
symptoms.
Acute asthma management includes the use of B-Agonist for a quick ;When B-agonists
are ineffective or required more than four times a day give bronchodilatator e.g.
salbutamol add oral corticoids (1-2mg/kg/day
for 3-5days eg dexamethazone,
prednisolone.
In case of acute severe asthmatic episodes (Status asthmaticus): Correct the significant
hypoxemia with supplemental oxygen. Mechanically assisted ventilation may be required
in alveolar hypoventilation.
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PROGNOSIS
There is no cure for asthma. Symptoms sometimes decrease over time. With repetitive attacks,
school absenteeism is one of the outcomes.
II.
A. DIARRHEA
Diarrhea is loss of watery stools (or bloody) for more than 3 times a day (more than 5 times a
day for the neonates and small infants). Acute diarrhea is a common problem that usually lasts 1
or 2 days, it can be prolonged and persist for more than 2 days and poses the risk of dehydration.
Chronic diarrhea may be a feature of a chronic disease.
Diarrhea is a common gastrointestinal problem during infancy and early childhood. In
developing countries, diarrhea causes around two million child deaths annually.
CAUSES OF DIARRHEA
Acute diarrhea
Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus,
cytomegalovirus, herpes simplex virus, and viral hepatitis.
Food intolerances. Some people are unable to digest food components such as lactose;
the sugar found in milk, infants can also have milk-protein allergies.
Parasites. Parasites can enter the body through food or water and settle in the digestive
system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica
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Chronic diarrhea
Diarrhea that persists longer than 4 weeks is considered to be chronic.
SIGNS & SYMPTOMS
-Frequent elimination: liquid stool (watery or bloody) accompanied by cramping, abdominal
pain, nausea. Depending to the cause, the child may have fever, vomiting.
DIAGNOSTIC
Stool culture
Stool examination
Blood tests
Sigmoidoscopy/ colonoscopy
COMPLICATIONS
MANAGEMENT OF DIARRHEA
- Prevent the dehydration by giving ORS (Oral Rehydrating Solution)
-Teach the mother on hygiene and sanitation
-To treat aetiology: e.g anti-infectious medication
- Zinc supplementation in children over 6 months: in developing countries, many children have
zinc deficiency. Zinc sulfate reduces the duration of diarrhoea and accelerates appetite
- Treat Dehydration
Table 1: Clinical assessment of degree of dehydration (Goldman et al., 2008)
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Degree of
dehydration
Mild
Moderate
(5-7% body weight) (7-9% body weight)
Severe
(>10% body weight)
Fontanelle
Mucous membranes
Slightly sunken
Slightly humid
Very sunken
Very dry
Markedly
decreased(2sec)
Delayed (3 seconds)
Decreased or absent
Irritable or lethargic
Skin turgor
Capillary refill time
Urine output
Mental status
Very sunken
Dry
Slightly
Normal
decreased(<2sec)
Normal (<3 seconds) Normal (<3 seconds)
Normal
Slightly decreased
Normal
Slightly fussy
Based on the degree of dehydration, the following approach to management has been suggested:
Table 2: Management of Dehydration
Degree of
dehydration
Management
Mild
Home-based treatment
Oral rehydration as the child needs; and give 50-100 ml for every watery stool
(<12months), 100-200ml for every watery stool ( 12months)
Moderate
oral rehydration therapy (ORS 75ml/kg in 4 hours) if the child vomits use
nasogastric tube
Reassess, if the child is now in mild dehydration, adjust the treatment.
Severe
Oral rehydration therapy include ORS with electrolytes, breastmilk and not tea, sugar drinks
such as apple juice and other juices, homemade remedies.
In a child, the normal fluid requirement (ORS) per 24 hours (maintenance therapy) is
approximately:
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decisive factors)
Colicky abdominal pain (and sudden ceasing of the diarrhea): intussusception?
Bloody diarrhoea
Inability to treat the child at home
Correction of the estimated dehydration is often possible by administration of a corrective
solution through a nasogastric tube at the outpatient department of a hospital. Afterwards,
the child is examined and weighed and can usually be discharged for follow-up care at
home.
If the child is in shock when referred, infuse Ringer solution 20 ml/kg in 15 minutes.
In a hospitalized patient, fluid balance parameters, CRP, basic blood picture and blood
gas analysis are examined.
B. PARASITOSIS
ASCARIASIS
This is caused by ascaris lumbricoides. It is seen more commonly in the children between the
age of one and five years with lower socioeconomic status (poor hygiene). It is transmitted
through contaminated food, water, hands, and utensils.
Manifestations
Ascaris pneumonia due to larvae in the lungs with dry cough (Lo ffler syndrome);
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Complications
In heavy infections, a large bolus of entangled worms can cause pain and small-bowel
obstruction, sometimes complicated by perforation or volvulus.
A large worm can enter and occlude the biliary tree, causing biliary colic, cholecystitis,
cholangitis, pancreatitis, or (rarely) intrahepatic abscesses.
Treatment: Mebendazole.
Prevention: - Hygiene (use of proper water to drink, to clean fruits and vegetables...)
- Encourage routine hand washing (e.g. after the toilet, before eating) in children
also should minimize infestation
- use of sanitary latrines minimize infestation
-For children under 5 years, give mebendazole 500mg every 3 months.
OXYUROSE
It is caused by Enterobius vermicularis and is transmitted because of unsanitary living
conditions in the school, hostel and families.
It is transmitted through contaminated soil, fingers, flies.
manifestations
General symptoms found:
loss of weight
lack of appetite
abdominal pain
diagnosis
Stool examination.
treatment
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AMOEBIASIS
It is caused by Entamoeba hystolitica and transmitted through ingestion of contaminated water,
food, hands...
Manifestations
Dysentery: diarrhoea with mucus stool accompanied by back pain after defecation
Diagnosis
Stool examination
Treatment
Metronidazole
C. CONSTIPATION
Functional constipation in childhood is currently defined by Rome criteria as 12 weeks (which
need not to be consecutive) over 12 months of hard stool, sensation of incomplete evacuation or
fewer than three defecations per week.
Physiology
Although breast-fed infants are less likely to develop constipation than those fed cow milkbased formulas their normal stool frequency can vary widely from seven per day to one every
7days.
Normal stool frequency ranges from an average of four per day during the neonatal period to two
per day by one year of age.
Diagnosis: Functional constipation is clinical diagnosis that can generally be made on the basis
of typical history and an essentially normal physical examination including one of the rectal
examination is a key part of the initial evaluation.
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Treatment
Education involves a clear explanation, of the disorder to the parents.
Oral polyethylene glycol is better tolerated if administrated with metoclopramide to enhance
gastric empting.
III. URINARY SYSTEM
A.WILMS TUMOUR
Wilms tumour is the tumour of the kidneys, that affect 1/10000 children younger than 15 years
of age.
It is associated with multiple congenital abnormalities and in some cases with identified
syndromes:
The exact cause is not known. It may be unilateral or bilateral. In most cases, the tumour is
vascular, soft in character.
Manifestation
The neoplasm metastasises early, in the perirenal tissue, lymph nodes, the liver, the diaphragm,
abdominal muscles and the lungs.
Staging
Stage I: Tumour limited to the kidney and completely excised
Stage II: Tumour beyond the kidney but completely excised
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ACUTE GLOMERULONEPHRITIS
Acute gromerulonephritis is a glomerular disease that can affect children. It is more common in
the age group of 2 to 10 years. It is immune complex disease due to antigen- antibody reaction
following haemolytic streptococcal infection, the antibodies affect the glomerulus causing
proliferation and swelling of endothelial cells, which increase the glomerular capillaries
permeability and lead to hematuria and proteinuria. The amount of the glomerulus is reduced and
it allows the passage of the blood cells and proteins into filtrate.
Manifestations
The symptoms develop about 1 to 3 weeks after the streptococcal infection.
Oedema start with the per orbital oedema in the morning, edema of the ankles, feet, and
occasionally ascites or pleural effusions
Urine out put is decreased with the high colour urine resembling black tea or coca-cola
due to lysis of red blood cells
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Hypertension may be present, and may cause headache, vomiting, somnolence, and other
central nervous system manifestations, including seizures.
The most severely affected children develop acute renal failure with oliguria.
investigations
1. Urine examination for:
-hematuria
-albumin
-white blood cells and epithelial cells
2. Blood examination for:
-urea nitrogen and creatinin
-Serum albumin
3 .Anti sreptolysin o titer (ASLO)
management
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Fluid should be supplied according to the prescription. The parents should be explained
about the accurate fluid intake.
Recreational facilities and play in the bed can help to divert the childrens mind.
NEPHROTIC SYNDROME
Nephrotic syndrome is a clinical state in which a group of symptoms can be developed in many
renal diseases, where there is increased glomerular permeability to pass plasma proteins.
Proteinuria increases and plasma proteins decrease.
Main characteristics of nephrotic syndrome are oedema, proteinuria, hypoalbunaemia, and
hypercholesterolemia.
Manifestations
Progressive gain in weight, oedema around the eyes, puffiness of the face which may become
generalized. If ascites increase, the child may become breathless
Vomiting, anorexia, and diarrhea may occur due to poor absorption because of the oedema of
the gastrointestinal mucosa.
Foamy urine
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Investigations
Blood for total serum protein and albumin and globulin levels
Serum cholesterol
Management
The fluid intake requirement is calculated according to the output and weight of the child
Observation of early signs of infection is necessary, because these patients have low
resistance.
Nutritional needs should be met with the diet containing high protein, for example eggs,
milk, soy bean, and ground nuts
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Plaque type in the most common form of psoriasis seen in children and adult.
The differential diagnosis includes seborrheic dermatitis, atopic dermatitis and bacterial
folliculitis (pustular variant)
Treatment and Prognosis
topical corticosteroids are used twice daily One is applied in the morning and the other is
applied in the evening
.Topic refined preparations such as liquor carbonic detergents can be combined with
corticosteroids and used once or twice daily.
SCABIES OR ITCH
Definition
Scabies are very tiny parasites (0.33mm in length) almost invisible to the naked eye, that live in
the folds to the skin, digging short, thin burrows in which they deposit their eggs, causing in this
way, irritation and itching. They do not suck blood but are nourished by cell wastes and the
exudates resulting from the irritation provoked. They may live in human skin for years,
periodically reproducing.
Mode of transmission
Direct transmission of the mites from a diseased to a healthy individual or , more infrequently ,
indirectly through clothing containing the mites or by sleeping in the same bed used by an
individual with scabies.
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There is no actual penetration, but external parasitism, since the mites like on the surface, inside
the epidermis.
Main risk of infection
Poor communities, with little personal hygiene, in which soap is not used and people
share crowded sleeping accommodation.
Treatment
* Hot bath followed by applications of a soapy emulsion of benzyl benzoate 25% or
anti scabies ointment, to be repeated for 2 consecutive days
* At the same time, sterilize the clothing, towels and sheets by boiling and dried on heat
* Treat all the member of the family who have scabies.
*treat itch and secondary infection if necessary
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PROPHYLAXIS
Individual
* Hygiene of the hand and skin
* Avoid contact with individual suspected of having scabies: Dont sleep in their bed, clothing or
towels
Collective
Health education which primarily aims to teach the rules of personnel hygiene. The habitual use
of soap in cleaning the body and knowledge of the causative agent of scabies (mites) the life
cycle and modes of transmission.
ORAL CANDIDOSIS
Definition:
Oral candidiasis is fungus disease causing thrush (fungus diseases especially of children
affecting mouth and throat.
Candida infection include superficial mucosal infection, such as oropharyngeal (thrush,) glositis,
and otitis external
There is many species of Candida that can cause this disease but the primary agent is Candida
albicans
Signs: white plaque covering the mucosa when scraped, these plaques usually reveal an easily
hemorrhagic .It can cover all or part of oral mucosa; it can be a discrete lesion or cover all of the
oro pharyngeal mucosa.
Diagnosis
-Diagnosis of Candida infection is supported by potassium hydroxide preparation or gram stain
of lesions fluids.
Biopsy specimens or by culture on standard.
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septicemia
Meningitis
Oesophageal candidosis
Digestive disorders
Treatment
-Nystatin
-In older children clotrimazole is recommended to keep the medication in contact with the lesion
longer.
-Daktarin gele of the mouth.
- The management concerns the: Complete diet, hygiene of the mouth, nasogastric tube.
V. NERVOUS SYSTEM (Meningitis, Convulsions, Encephalitis.)
A. CONVULSIONS
Definition:
Convulsions are violent motion of the limbs or body caused by involuntary contraction of
muscles.
Causes
Convulsions can be conditioned by
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Epilepsy
Breathing difficulty
Whooping cough
Brain inflammation
Meningitis
Encephalitis
Head injury
Brain tumor
Hypoglycemia
Stroke
Alcohol withdrawal
Febrile convulsions: occur in young children when there is a rapid increase in their body
temperature. It affects up to 1 in 20 children between the ages of one and four but can affect
children between six months and about five years old.
Children who are at risk may naturally have a lower resistance to febrile convulsion than others.
Symptoms of Convulsions
The signs and symptoms mentioned in various sources for Convulsions includes the following:
Body twitching
Body spasms
Jerking limbs
Head spasms
Facial spasms
Bladder incontinence
Bowel incontinence
Loss of consciousness
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Complications
Complications and sequelae of Convulsions include:
Incontinence
Falls, injuries
Treatment
Phenytoin
Phenobarbital
Diazepan
MENINGITIS
Meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal
cord. It is usually caused by bacteria, viruses, or fungi but it can also be caused by certain
medications or illnesses.
Bacterial meningitis is rare, but is usually serious and can be life-threatening if it's not treated
right away. Viral meningitis (also called aseptic meningitis) is relatively common and far less
serious. It often remains undiagnosed because its symptoms can be similar to those of the
common flu.
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Kids of any age can get meningitis, but because it can be easily spread between people, living in
close quarters, teens, college students, and boarding-school students are at higher risk for
infection.
If dealt promptly, meningitis can be treated successfully. So it is important to get routine
vaccinations and know the signs of meningitis
Transmission
Most cases of meningitis (both viral and bacterial) result from infections that are contagious,
spread via tiny drops of fluid from the throat and nose of someone who is infected. The drops
may become airborne when the person coughs, laughs, talks, or sneezes. They then can infect
others when people breathe them in or touch the drops and then touch their own noses or mouths.
Sharing food, drinking glasses, eating utensils, tissues, or towels all can transmit infection as
well. Some infectious organisms can spread through a person's stool, and someone who comes in
contact with the stool such as a child in day care may contract the infection.
The infections most often spread between people who are in close contact, such as those who
live together or people who are exposed by kissing or sharing eating utensils.
Causes of Meningitis
Many of the bacteria and viruses that cause meningitis are fairly common and are typically
associated with other routine illnesses. Bacteria and viruses that infect the skin, urinary system,
gastrointestinal or respiratory tract can spread by the bloodstream to the meninges through
cerebrospinal fluid, the fluid that circulates in and around the spinal cord.
In some cases of bacterial meningitis, the bacteria spread to the meninges from a severe head
trauma or a severe local infection, such as a serious ear infection (otitis media) or nasal sinus
infection (sinusitis).
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fever
lethargy
irritability
headache
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stiff neck
skin rashes
seizures
Infants with meningitis may not have those symptoms, and might simply be extremely irritable,
lethargic, or have a fever. They may be difficult to be comforted, even when they are picked up
and rocked.
Other symptoms of meningitis in infants can include:
poor feeding
a weak suck
a high-pitched cry
bulging fontanel
Viral meningitis tends to cause flu-like symptoms, such as fever and runny nose, and may be so
mild that the illness goes undiagnosed. Most cases of viral meningitis resolve completely within
7 to 10 days, without any complications or need for treatment.
Diagnosis
Because bacterial meningitis can be so serious, if you suspect that your child has any form of
meningitis, it's important to do investigation to confirm or to exclude the illness.
The tests will likely include a lumbar puncture (spinal tap) to collect a sample of spinal fluid.
This test will show any signs of inflammation, and whether a virus or bacteria is causing the
infection.
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Treatment
*A child who has viral meningitis may be hospitalized, although some kids are allowed to
recover at home if they are not too ill. Treatment, including rest, fluids, and over-the-counter
pain medication, is given to relieve symptoms (e.g. paracetamol)
*If bacterial meningitis is diagnosed, or even suspected:
- start intravenous (IV) antibiotics as soon as possible ( e.g. cefotaxim, ceftriaxon, Ampicilline+
gentamycine)
- Fluids may be given to replace those lost to fever, sweating, and vomiting,
- corticosteroids may help reduce inflammation of the meninges, depending on the cause of the
disease. (e.g. head trauma)
- anticonvulsants might be given for seizures.
- Some kids may need supplemental oxygen or mechanical ventilation if they have difficulty
breathing.
Complications & prognosis
hearing loss,
visual impairment,
seizures, and
Although some kids develop long-lasting neurological problems, most who receive
prompt diagnosis and treatment recover fully.
Prevention
* Routine immunization: the vaccines against Hib, measles, mumps, polio, meningococcus, and
pneumococcus can protect against meningitis caused by these microorganisms.
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* In certain countries, the 11 years old get vaccinated for meningococcal disease, a serious
bacterial infection that can lead to meningitis. The Children who have not had the vaccine and
are over 11 years old should also be immunized, particularly if they're going to college, boarding
school, camp, or other settings where they are going to be living in close quarters with others.
This vaccine may also be recommended for people who are travelling to countries where
meningitis is more common.
* Good hygiene is an important way to prevent any infection: encourage kids to wash their hands
thoroughly and often, particularly before eating and after using the toilet.
* Avoiding close contact with someone who is obviously ill and not sharing food, drinks, or
eating utensils can help stop the spread of germs as well.
* In certain cases, may decide to give antibiotics to anyone who has been in close contact with
the person who is ill to help prevent additional cases of illness.
ENCEPHALITIS
Encephalitis literally means an inflammation of the brain, but it usually refers to brain
inflammation caused by a virus. It's a rare disease that occurs in approximately 0.5 per 100,000
individuals most commonly in children, the elderly, and people with weakened immune systems
(i.e., those with HIV/AIDS or cancer).
Although several thousand cases of encephalitis (also called acute viral encephalitis or aseptic
encephalitis) are reported to the Centers for Disease Control and Prevention (CDC) every year,
experts suspect that many more may go unreported because the symptoms are so mild.
Signs and Symptoms
* Symptoms in milder cases of encephalitis usually include:
fever
headache
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poor appetite
loss of energy
a general sick feeling
High fever
severe headache
stiff neck
confusion
disorientation
personality changes
convulsions (seizures)
hallucinations
memory loss
Difficulty in walking
drowsiness (lethargy)
coma
It's harder to detect some of these symptoms in infants, but important signs to look for include:
Vomiting
crying that doesn't stop or that seems worse when an infant is picked up or handled in some
way
body stiffness
Causes
Because encephalitis can be caused by many types of germs, the infection can be spread in
several different ways.
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- One of the most dangerous and most common causes of encephalitis is the herpes simplex
virus (HSV). HSV is the same virus that causes cold sores around the mouth, but when it attacks
the brain it may occasionally be fatal. Fortunately, HSV encephalitis is very rare.
- Encephalitis can be a very rare complication of Lyme disease transmitted by ticks, or of rabies
spread by rabid animals.
- Milder forms of encephalitis can follow or accompany common childhood illnesses, including
measles, mumps, chickenpox, rubella, and mononucleosis. Viruses like chickenpox spread
mostly via the fluids of the nose and throat, usually during a cough or sneeze.
- Less commonly, encephalitis can result from a bacterial infection, such as bacterial meningitis,
or it may be a complication of other infectious diseases like syphilis.
- Certain parasites, like toxoplasmosis, can also cause encephalitis in people with weakened
immune systems.
Prevention
- Encephalitis cannot be prevented except to try to prevent the illnesses that may lead to it.
- Encephalitis that may be seen with common childhood illnesses can be largely prevented
through proper immunization.
- Kids should also avoid contact with anyone who already has encephalitis.
Diagnosis
- Imaging tests, such as computed tomography (CT) scans or magnetic resonance imaging
(MRI), to check the brain for swelling, bleeding, or other abnormalities
- Electroencephalogram (EEG), which records the electrical signals in the brain, to check for
abnormal brain waves
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- Blood tests to confirm the presence of bacteria or viruses in the blood, and whether a person is
producing antibodies (specific proteins that fight infection) in response to a germ
- Lumbar puncture, in which cerebrospinal fluid is checked for signs of infection
Treatment
Hospitalization
Antiviral drugs can be used to treat some forms of encephalitis, especially the type
caused by the herpes simplex virus.
Evolution & complications: For most forms of encephalitis, the acute phase of the illness (when
symptoms are the most severe) usually lasts up to a week. Full recovery can take much longer,
often several weeks or months. Most people with encephalitis make a full recovery.
In a small percentage of cases, some complications may occur, including:
- learning disabilities,
- speech problems,
- memory loss, or
- lack of muscle control.
- Rarely, if the brain damage is severe, encephalitis can lead to death. Infants younger than 1 year
are at greatest risk of death from encephalitis.
VI. ENDOCRIN SYSTEM
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DIABETES MELLITUS
Diabetes mellitus (DM) or simply diabetes is a chronic health condition in which the body either
fails to produce sufficient amount of insulin (reduced insulin secretion) or responds abnormally
to insulin (decreased glucose utilization). The ultimate outcome for all the types of diabetes is
high blood glucose level or hyperglycemia.
TYPES OF DIABETES MELLITUS
1. Type 1 diabetes: insulin deficiency
2. Type 2 diabetes: insulin resistance
3. Gestational Diabetes Mellitus (GDM)
Type 1 diabetes
Etiology
- Genetic factor
-Immune-mediated = cell destruction, usually leading to absolute insulin deficiency
-Idiopathic
- Pancreatitis with destruction of islet cells
- Some viruses such as rubella, mumps, coxsackie, cytomegalovirus are related to the destruction
of beta cells.
Pathophysiology
Type 1 diabete result from a severe, absolute lack of insulin caused by loss of beta cells.
Destruction of islet cells is related to genetic susceptibility and autoimmunity. There are islet cell
autoantibodies that participate in damage of islet cells. When 80% to 90% of the insulinsecreting beta cells of the islet of Langerhans are destroyed, then the hyperglycemia and other
symptoms occur.
The pathophysiology of diabetes mellitus (all types) is related to the hormone insulin, which is
secreted by the beta cells of the pancreas. This hormone is responsible for maintaining glucose
level in the blood. It allows the body cells to use glucose as a main energy source. However, in a
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diabetic person, due to abnormal insulin metabolism, the body cells and tissues do not make use
of glucose from the blood, resulting in an elevated level of blood glucose or hyperglycemia.
Over a period of time, high glucose level in the bloodstream can lead to severe complications,
such as eye disorders, cardiovascular diseases, kidney damage and nerve problems.
Manifestations
Polydipsia
Polyuria
Polyphagia
Weight loss: the glucose is not used by cells because there is lack of insulin, so, fats and
proteins are used as source of energy.
Fatigue
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Treatment
- Insuline in case of type 1 diabetes, and in late stage of type 2 diabetes
- Oral hypoglycemiant agents in type 2 diabetes in early stages
- Dietetic measures
- Monitor glycemia before meal and before bedtime
Complications
Acute complications
- Diabetic ketoacidosis: with hyperglycemia and ketonuria manifested by acetone smelling
(fruity odor)
- Hyperosmolar coma: with hyperglycemia(> 600mg/dl) and dehydration
- Hypoglycemia
Chronic complications
- Hypertension
- Prolonged wound healing
- Infection
- Neuropathy
- Nephropathy
EDUCATION
- Education about signs and symptoms of hypoglycemia
- During any journey, the patient should carry the drugs on him/her. The diabetic card is also
necessary, and the patient should not forget to carry some foods or fluid containing sugar to take
in case of hypoglycemia
- Education on self injection: number of injections per day, way of administration (S/C route)
and site of injection
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Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years
in developing countries and contributes indirectly to over half the deaths in childhood
worldwide.
KWASHIORKOR
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It is a severe deficiency of protein. This type of malnutrition in children often occurs after the
children weaned between age of 18 and 48 months. It is caused by deficiency in protein, and is
characterized by edema.
Causes & Risk factors
Weaning: early weaning associated with poverty, late weaning also predispose to
kwashiorkor
Short interval between birth: the first child will be neglected and may get kwashiorkor
Twins
Culture: taboos
MARASMUS
Marasmus is a state of starvation due to calories deficiency, in which almost all muscle fat is
used, characterized by reduced muscle skinfold, the appearance of necked bone and the child that
is look like a worried old man.
Causes & risk factors
Elements of comparison
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Marasmus
Kwashiorkor
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cause
Clinical features
Well-nourished appearance
Laboratory findings
g/dl
Diagnostic criteria
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improper absorption
Anthropometric measures
weight
height
Skinfold thickness
Using Z- score, check weight for age, weight for height, and height for age Z- score according to
sex. a Z-score with a standard deviation -2 is considered abnormal. Thus an abnormal Z- score
or abnormal MUAC explains one or another form of malnutrition (severe or moderate, acute or
chronic).
Other tests
-
Stool examination
MANAGEMENT
Prevention
Immunization
Encourage the family and the community on home gardens and the use of the available
food to prevent malnutrition
Advice on both environmental and personal hygiene to prevent repetitive diarrhea that
can be a factor of malnutrition
Help the community to know the source of carbohydrates such as rice, vegetable,
cassava, wheat, Irish potatoes, cereals, grains, sweet potatoes, sugar, honey, and the
source of proteins such as eggs, meat, fish, beans, soy beans, peas, milk
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Surveillance of the childs weight, height, MUAC through monthly follow-up of the
children under 5 years, in order to detect early the symptoms of malnutrition, and act
accordingly.
Treatment
Regular weighing of children to assess the evolution (Children with edema must be
assessed carefully for actual nutritional status because edema may mask the severity of
malnutrition).
In utero: 5-8 %
Perinatal: 10-20%
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Postnatal: 14-20%
Advanced state of the infection for the mother (increased viral load)
primo infection
Obstetrical factors
episiotomy
Twin pregnancy
Dystocic birth
primary prevention by IEC on the spread of sexual transmitted infections and voluntary
HIV testing
prevention of unwanted pregnancies by using family planning methods for those who are
infected
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safe methods of birth and breastfeeding: e.g Tritherapy for the mother when starting
labour, and Niverapine for the infant within 6-12 hours and continue up to 6 weeks (see
the new PMTCT protocol 2011,). Minimize the risk for infection by promoting C- section
especially for those with STIs and vaginal ulcerations, minimizing vaginal examination,
episiotomy and avoiding amniocentesis.
Breastfeeding avoidance may be helpful for the mothers who have other source of
nutrients. If breastfeeding is adopted, exclusive breastfeeding in 6 months, then introduce
appropriate food and continue breastfeeding for 12 months.
ANTIRETROVIRAL DRUGS FOR TREATING PREGNANT WOMEN
AND PREVENTING HIV INFECTION IN INFANTS (2010 WHO recommendations)
Antiretroviral treatment options recommended for HIV-infected pregnant
women who are eligible for treatment
Eligibility criteria
- CD4 350/mm3 regardless on clinical stages
- clinical stages 3 or 4 regardless on CD4 cell count
Maternal ART + infant ARV prophylaxisher
Maternal antepartum daily ART, starting as soon as possible irrespective of gestational age, and
continued during pregnancy, delivery and thereafter. Recommended regimens include:
AZT + 3TC + NVP or
AZT + 3TC + EFV* or
TDF + 3TC + NVP or
TDF + 3TC + EFV*
Infant
Infant: Daily NVP or twice-daily AZT from birth until 4 to 6 weeks of age (irrespective of the
mode of infant feeding).
Two options are recommended for HIV-infected pregnant women who are not eligible for
ART: option A is maternal AZT + infant ARV prophylaxis; option B is maternal triple ARV
prophylaxis.
Option A: maternal AZT + infant ARV prophylaxis
- antepartum twice-daily AZT, plus sd-NVP at the onset of labour , plus twice daily
AZT + 3TC during labour and delivery and continued for 7 days postpartum.
- In breastfeeding infants, daily administration of NVP to the infant from birth until 1
week after all exposure to breast milk has ended, or for 4 to 6 weeks if breastfeeding
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stops before 6 weeks (but at least 1 week after the early cessation of breastfeeding), is
recommended.
- In infants receiving only replacement feeding, daily administration of NVP from birth
or sd-NVP at birth plus twice-daily AZT from birth until 4 to 6 weeks of age is
recommended.
Option B: maternal triple ARV prophylaxis
- antepartum daily triple ARV prophylaxis until delivery, or,
- if breastfeeding, until 1 week after all exposure to breast milk has ended.
Recommended regimens include
AZT + 3TC+ LPV/r,
AZT + 3TC + ABC,
AZT + 3TC + EFV, or
TDF + 3TC + EFV.
a) Clinical care:
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STAGES
CHARACTERISTICS
Stage I
Primo-infection
Stage II
Stage III
Opportunistic diseases
Stage IV
Paediatric classification of HIV infection stages according to CDC (Centre for diseases
control): immunologic evaluation
Stages
No
0-11 months
immunity CD4 1500 / l
1-5 years
6-12 years
CD4 1000 / l
CD4 500 / l
deficiency
Moderate deficiency
CD4 750-1499 / l
CD4 500-999 / l
CD4 200-499 / l
Severe deficiency
CD4 <750 / l
CD4 <500 / l
CD4 <200 / l
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Proposed CD4 thresholds for initiation of ART in infants and children; WHO stages
< 18 months
18-35
months
36-60 months
> 5years
Treat all
<1000
<750
<350
Criteria
CD4/l
Note: The new national protocol (2011) proposes that all children under 5 years of age who are
HIV positive are treated with ARVs regardless of their CD4 cell count or clinical stage. (for
details, see new PMTCT protocol 2011)
ART regimen in children
1st and 2nd line regimen in non-exposed to sd NVP (PMTCT exposure)
ABC+3TC+EFV/NVP
Alternative 1st line regimen
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AZT+3TC+LPV/RTV
Alternative 2nd regimen
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AZT+3TC+EFV/NVP
ABC+3TC+LPV/RTV
Recommended 2 nd line
AZT+ 3TC+ LPV/RTV
Alternative
AZT+ 3TC+ LPV/RTV
Alternative
ABC+ 3TC+ LPV/RTV
b) Psychological care:
assess the child for psychological problems and give support through counseling (
counseling of the family, counseling of the child, group support)
c) Social care:
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stigma prevention
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Advocate for school adherence: some NGOs help HIV- infected children in
school affairs, by paying school fees, providing school materials
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Paraphimosis
b) Paraphimosis
The retracted foreskin can constrict the penis, causing edema of the glans.
Causes: it may happen after rigorous cleaning, catheter insertion
Treatment: If the foreskin cannot be reduced manually, surgery (circumcision) must be
performed to prevent necrosis of the glans caused by constricted blood vessels.
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2. CRYPTORCHIDISM
The cryptorchidism is a condition whereby one or both testes fail to descend into the scrotum. It
is the most common congenital condition involving the testes.
About 3% to 6% of all full-term males and 20% to 30% of all premature males have
undescended testes at birth.
The testes may remain in the abdomen, or descent may be arrested in the inguinal canal
or the puboscrotal junction.
In approximately 75% to 90% of infants with cryptorchidism, the testes descend into the
scrotum by 1 year of age.
Causes
Developmental delay
Some mechanical factor that prevents descent through the inguinal canal such as*short
spermatic cord, *fibrous bands or adhesions in the normal path of the testes, * or
narrowed inguinal canal.
Cryptorchidism does not prevent puberty or maintenance of secondary sex characteristics if the
testis is otherwise normal.
Complications
-
Infertility if untreated
Neoplastic processes: the undescended testes are susceptible to cancer with the risk of 35
to 50 times greater for men with cryptorchidism or a history of cryptorchidism than for
the general male population.
Physical examination
Palpation of the scrotum: Absence of one or both testes in the scrotum
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Diagnosis
Ultrasonography or a CT scan can help clinicians locate a non palpable testis that has
migrated intra-abdominally.
Treatment
-
Placement of the cryptorchid testes into the scrotal sac does not decrease the potential
for malignancy, but it does facilitate the examination and tumor detection.
Clinic
Torsion twists (make a helix) the arteries and veins in the spermatic cord, reducing or
stopping circulation to the testis.
Vascular engorgement and ischemia develop, causing acute scrotal swelling and severe
pain not relieved by rest or scrotal support
Treatment
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4. HYPOSPADIAS
Definition: A condition where the urethral orifice opens in abnormal position on the ventral
surface of the penis or scrotum.
Causes /risk factors
- Use of maternal estrogen or progesterone during pregnancy
- Hereditary
Signs and symptoms
- Difficulty directing the urinary stream and stream spraying
- Chordee
- Males with this condition often have a downward curve (ventral curvature or chordee) of the
penis during an erection
- Abnormal spraying of urine
- Having to sit down to urinate
- Malformed foreskin that makes the penis look hooded
Investigations
- A physical examination can diagnose this condition
- A buccal smear and karyotyping
- Urethroscopy
- cystoscopy
- Excretory urography
Complications
- Difficulty with toilet training
- Problems with sexual intercourse in adulthood
- Urethral strictures and fistulas may form throughout the boys life
Management
- Infants with hypospadias should not be circumcised
- For a Minor degree of hypospadias (e.g. glandular hypospadias) require no treatment
Surgical management: During the surgery, the penis is straightened and the hypospadias is
corrected using tissue grafts from the foreskin. The repair may require multiple surgeries
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5. HERNIAS
a) INGUINAL HERNIA
An inguinal hernia can occur any time from infancy to adulthood and is much more
common in males than females. It is the 2 nd hernia in childhood, after umbilical hernia.
TYPES
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A direct hernia develops gradually because of continuous pressure on the muscles. One or more
of the following factors can cause pressure on the abdominal muscles and may worsen the
hernia:
weight gain
chronic coughing
Indirect and direct inguinal hernias usually slide back and forth spontaneously through the
inguinal canal and can often be moved back into the abdomen with gentle massage.
Symptoms
Complications
Incarceration: Incarcerated inguinal hernia is a hernia that becomes stuck in the groin
or scrotum and cannot be massaged back into the abdomen.
Strangulation: a strangulated hernia, in which the blood supply to the incarcerated small
intestine is limited, is a serious condition and requires immediate medical attention.
Symptoms of strangulation include:- extreme tenderness and redness in the area of the bulge,
- sudden pain that worsens quickly,
- fever and rapid heart rate,
- nausea, and vomiting.
Diagnosis
Inguinal hernia is diagnosed through physical examination
Treatment
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Surgery: herniorraphy
b) UMBILICAL HERNIA
Definition: It is a bulge in the navel due to intestine, fat, or fluid that pushes through a hole in
the babys abdomen muscles (umbilical ring that is not closed just before birth).
Cause
The ring of muscle and other tissue that forms where blood vessels in the umbilical cord enter a
fetus's body is known as the umbilical ring. This ring usually closes before the baby is born. If it
does not close, tissue may bulge through the opening, creating an umbilical hernia.
Clinical manifestations
An umbilical hernia is usually seen after the umbilical cord stump falls off, within a few weeks
after birth. But some children dont get a hernia until they are infants or toddlers.
Symptoms may include: - A soft bulge under the skin of your childs belly button (navel)
- The part of the bulge can be pushed back in
- The bulge may be easier to see when your child sits or stands upright
or when a child is crying, coughing, or having a bowel movement.
- Most children don't feel pain from the hernia.
- The child may experience vomiting and signs of infection such as
redness and swelling on the belly button associated with fever.
Diagnosis
Umbilical hernia is diagnosed through physical examination.
Treatment
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Umbilical hernias usually close on their own before a baby is 1 year old. If a hernia has not
closed by the time your child is 5 years old, your child probably will need surgery to close it.
The child may have surgery before he or she is age 5 if:
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1. SNAKEBITES
Epidemiology
Venomous snakes bite rates are highest in temperate and tropical regions where the population
subsists by manual agriculture. Estimates indicate >5 million bites annually by venomous snakes
worldwide, with >125,000 deaths.
Clinical Manifestations
-
Local swelling
Pain (myalgia)
Ecchymosis
Neurotoxins of the venom inhibit peripheral nerve impulses and can cause ptoses, altered
mental status
Severe poisoning may result in paralysis, including the muscles of respiration, and lead to
death due to respiratory failure and aspiration.
Hemorragins molecular of the venom promote vascular leakage and cause both local and
systemic bleeding including hemorrhagic bullae and serum-filled vesicles.
Treatment
Field Management
-
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Hospital Management
-
Any patient with signs of venom poisoning should be observed in the hospital for at least
24 h.
The victim should be closely monitored (vital signs, cardiac rhythm, oxygen saturation,
urine output) while a history is quickly obtained and a rapid, systematic physical
examination is performed.
The level of swelling in a bitten extremity should be marked and limb circumferences
measured in several locations every 15 min until swelling has stabilized.
Fluid resuscitation with Normal saline should be initiated for clinical shock.
Indications for antivenom administration in victims of viperid bites include any evidence
of systemic envenomation (systemic symptoms or signs; laboratory abnormalities) and
(possibly) significant, progressive local findings (e.g., soft tissue swelling crossing a joint
or involving more than half the bitten limb in the absence of a tourniquet).
For viperid bites, antivenom administration should generally be continued as needed until
the victim shows definite improvement (e.g., stabilized vital signs, reduced pain, restored
coagulation).
Neurotoxicity from elapid bites may be harder to reverse with antivenom. Once
neurotoxicity is established and endotracheal intubation is required, further doses of
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antivenom are unlikely to be beneficial. In such cases, the victim must be maintained on
mechanical ventilation until recovery occurs, which may take days to weeks.
-
Care of the bite wound includes application of a dry sterile dressing and
splinting/immobilization of the extremity with padding between the digits.
Once the administration of an indicated antivenom has been initiated, the extremity
should be elevated above heart level to relieve edema.
A dose of IV mannitol (1 g/kg) can be given in an effort to reduce muscle edema if the
patient's hemodynamic status is stable.
Wound care in the days after the bite may require careful aseptic debridement of clearly
necrotic tissue once coagulation has been restored. Intact serum-filled vesicles or
hemorrhagic blebs should be left undisturbed. If ruptured, they should be debrided with
sterile technique.
In the event of serum sickness (fever, chills, urticaria, myalgias, arthralgias, and possibly
renal or neurologic dysfunction developing 12 weeks after antivenom administration),
the victim should be treated with systemic glucocorticoids (e.g., oral prednisone, 12
mg/kg daily) until all findings resolve, at which point the dose is tapered over 12 weeks.
Oral antihistamines (e.g., diphenhydramine in standard doses) provide additional relief of
symptoms.
2. BEE STING
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Honeybees often lose their stinging apparatus and the attached venom sac in the act of stinging
and subsequently die.
Manifestations
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- immediate pain,
- a wheal-and-flare reaction,
- local edema and swelling that subside in a few hours.
*Stings from accidentally swallowed insects may induce life-threatening edema of the upper
airways.
*Multiple stings can lead to:
- vomiting,
- diarrhea,
- generalized edema,
- dyspnea,
- hypotension, and collapse.
- intravascular hemolysis may cause renal failure.
- Death from the direct effects of venom has followed 300500 honeybee stings.
Treatment
-
The site should be cleansed and disinfected and ice packs applied to slow the spread of
venom.
Give the steroids ( e.g. Oral prednisolone) in case of large local reactions.
Patients with numerous stings should be monitored for 24 h for evidence of renal failure
or coagulopathy.
In case of anaphylaxis:
. Give Epinephrine
. A tourniquet may slow the spread of venom.
. Give parenteral antihistamines,
. fluid resuscitation,
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. bronchodilators,
. oxygen and intubation.
.Patients should be observed for 24 h for recurrent anaphylaxis.
II.
INGESTION OF CHEMALS
1. INGESTION OF HYDROCARBONS
Hydrocarbon is the one of the most toxic exposures, usually occurring in children younger than 5
years old. Hydrocarbons are commonly used as fuel, polishes,
Ingested hydrocarbons generally produce little systemic toxicity, but during ingestion they pose a
serious risk of pulmonary aspiration. Hydrocarbons destroy pulmonary surfactant, leading to
ventilation- perfusion mismatch, hypoxia.
Manifestations
-
Gastric lavage
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Manifestations
-
Severe pain
Spontaneous vomiting
Dilution with milk or water may be helpful if given within the 1 st few minutes after the
exposure in those who have no airway complains, vomiting, no abdominal pain, and are
able to speak.
III.
Drug overdose is common among children less than 6 years of age. Poisoning due to drug
overdose may be local (e.g., skin, eyes, or lungs) or systemic depending on the chemical and
physical properties of the poison, its mechanism of action, and the route of exposure.
Management
Treatment goals include:
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a) Supportive care
Airway protection
Oxygenation/ventilation
Treatment of arrhythmias
Hemodynamic support
Treatment of seizures
Gastrointestinal decontamination
Gastric lavage
Activated charcoal
Whole-bowel irrigation
Dilution
Endoscopic/surgical removal
Eye decontamination
Skin decontamination
Diuresis
Alteration of urinary pH
Extracorporeal removal
Peritoneal dialysis
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Hemodialysis
Hemoperfusion
Hemofiltration
Plasmapheresis
Exchange transfusion
Hyperbaric oxygenation
Administration of Antidotes
Neutralization by antibodies
Metabolic antagonism
Physiologic antagonism
Prevention of Reexposure
Child-proofing
ACETAMINOPHEN OVERDOSAGE
Acetaminophen ( Paracetamol ) is the most common pharmaceutical agent involved in overdose.
Clinical features
An acute ingestion 150-200mg/kg of acetaminophen in a child is potentially hepatotoxic.
Early after the acute overdose, there are minor symptoms like: Nausea, vomiting and
anorexia.
Approximately 36 hours after ingestion: * transaminase levels rise, *Encephalopathy,
*metabolic acidosis, *increasing prothrombin time.
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Differential diagnosis
Viral hepatitis
Hepatobiliary disease
Management
Activated charcoal within1-2 hours
Give N-acetylcystein within8 hours of ingestion to prevent hepatotoxicity. Oral or via
nasogastric tube 140mg/kg loading dose, then 70mg/kg every 4 hours for 17 doses.
Antiemetics may be necessary
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Clinical Features
Poisons
Odour of Breath
Hypertension
with Tachycardia
Hypotension with
bradycardia
Hyperthermia
Hypothermia
Tachypnoea
Bradypnoea
Altered sensorium
Antidepressants, Antihistamines,
Antipsychotics,
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Atropine, Organophosphates, Barbiturates,
Lithium,
Cyanide, Benzodiazepines, Ethanol,
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