Inpatient Peds

Childrens Hospital Philadelphia Clinical Pathways - Inpt / Output / ED

McMasters Peds Handbook
UF Peds Handbook
Pets / Derm Description of Rashes

PCH ER Note

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- Vaccines stated UTD.
ROS: no dizziness/HA, no cough/wheezing, no CP/palpitations, no cough/wheeze, no diarrhea/constipation, no rash/joint pain.


AP
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- ddx:
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>


Reassessment
VSS. Appears well, sx improved.
Given precautions to RTC;
Otherwise, f/u PCP within the next 1 wk.



Common Rx Dosages

Ibuprofen 10mg/kg q6-8hr
APAP 15mg/kg q4-6hr
Toradol 0.5 mg/kg IV
Zofran 0.15 mg/kg q4-8hr (ok >6mo old)
Benadryl 1mg/kg q6-8hr
Decadron 0.6mg/kg (12mg max; duration 48hr fx)


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Pediatric vital signs normal ranges



PMHx
Infant: BW, Pre/Term, SVD/CS, PNC, location, newborn course, jaundice/infections.
Child/Teen: Pre/Term, SVD/VS, newborn cx.
Imm: UTD, Flu, tetanus last.

PE:
• PEWS Score


Daily:
• Diet:
• Consults: PT/OT, Childlife, Nutrition


Admit Order Sets:
1. Clean out:
• Senna, Miralax, Mineral oil / fleet enema.
• IVF:
• NPO, NG to suction

Sepsis / Bacteremia:
• GNR: very very bad : zosyn right away
- increasing
• 



Hyperbilirubinemia
CHOP Hyperbili
• key decision points : physiologic vs pathologic? risk stratification?
• PE: jaundice head->toe (
• Hx: birth hx, infix risks, feeds.
• Cx: jaundice, encephalopathy / kernictierus (if chronic)
• tx options: phototherapy (bhutani curve), transfusion
• Phototherapy treatment: q12-24hr tx, then recheck tbili, then a 12hr for rebound. measure the rate of rise. Tx goal is <0.2 rise and also plotted below the treatment for the Bhutan curve.
• Physiologic hyperbili = mc is breastfeeding jaundice / dehydration (poor PO intake, plus initial increased bill load and low hepatic processing power).
• Pathologic jaundice / hyperbili = mc is hemolysis; ex. Rh isoimmunization, ABO incompatibility. Need to dig deeper.

Physio
- clearance: conjugation -> excretion in bile -> 90% stool, 10% urine.
- unconjugated bili = neurotoxic.

Px:
- neuro: irritable / lethargy / cry / poorfeed / apnea / azrs
- jaundice : head->toe;

Hx:
- delivery, infxn risk, feeds / hydration - i/os.
- isoimmunization
- fhx / ethnicity: g6pd, spherocytosis
- PE: activity, feeding, bruise/hematoma

Dx:
- measure tBili and direct bili; tx plan based on tbili.
- also: BT/rh mom + baby, DAT/coombs, CBC (retic, smear).

Management
- physiologic vs pathologic?
- indirect vs direct?
- baby term or pre? pre = less hepatic enzyme activity, easier for encephalopathy at lower bili levels

Indirect hyperbili:
- physiologic, disorders production / hepatic uptake, conjugation
> physiologic: 48hr-120 hr (day 2-day 5) progressive rise. 2/2 lower liver activity w/ higher load bili. in every newborn to some degree.
- disorders production : high RBC lysis = isoimmunization, RBC defects biochemical / structural, infxn, sequestration (bruising. hematomas).
- defect uptake / conjugation: gilberts, crigler-najjar
- other: lack volume (breastfeeding jaundice), breast milk jaundice

Direct hyperbili:
- definition: >2mg/dL (severe >5mg/dL), >15% tbili
- icteric, acholic stools, dark urine
- etio: TPN-associated, hepatitis, infxn, biliary block (atresia, bile plug, cyst)

Tx options:
- phototherapy, IVIg, exchange transfusion, phenobarb.

Phototherapy nomogram
Exchange transfusion nomogram

Pathologic jaundice definition
Present in first 24 hours of life
TSB level > age-specific 95th percentile
TSB rising by > 0.2 mg/dL per hour
Conjugated bilirubin (BC) > 1.5 mg/dL or > 20% of TSB





Bronchiolitis.
PDF review case. (CHOP Bronchiolitis Tx pathway)
• DDx: PNA, foreign body aspiration, chronic plum dz, CHD, vascular ring. 
• DDx vs asthma: if recurrent wheeze / hx CS use, >12 mo, strong response to albuterol
     - 1/2 hospitalized bronchiolitics will go to asthma. 
• DDx vs PNA: sicker pts, focal LRT findings. 
• <2 yo px URTi sx, then LRTi (wheeze, cough, rales)
• Etio: Viral (1/2RSV; rhino; paraflu, metapneumo)
• MOP: viral-> acute inflame, edema, necrosis @ bronchials -> mucus, spasm. 
• Course: URTi 2 days -> LRTi 4 days -> full recovery 2-8 wks. 
• RSV ab ppx if : chronic lung dz, <32 wk premie, sig CHD, severe immunodeficient.
• Dx: clinical, hx (URTi -> LRTi),  w/u to r/o other etios.
• W/u: viral panel, CXR (not routine, use if severe, r/o other dx)
• cx: AOM is common!
• Tx: stratify => mild - supportive, mod - albuterol trial, severe - NPO, albuterol, +/- CS, epi. PICU?
• Tx: supportive care (suction URT, CPT, hydration, O2).
• Rx: B-agonist, CS, ribavarin (last line?); evidence insufficient to recommend any rx!
     > if w/ distress, albuterol trial, possibly epi, CS. 
• New AAP recs: no testing for specific virus, no routine XR or labs, no trial B-ag, no epi / CS. just spportive. no abx. 
• Dc Criteria: O2 sat >90% awake x3 - 4hrs apart off NC (or overnight off O2, lowest O2 is sleeping), RR<70, good PO, mild work breathing, f/u care, asthma treatment plan. 


Child w/ Limp: 
• Kocher Score: for septic joint.
• US for effusion, b/l hip XR for necrosis / fx.

Pancreatitis: 
Etio: MC TRAUMA; rx; gallstone

Gastroenteritis


Failure to Thrive
• daily weights, I/Os.
• consult: nutrition

ERD
ddx vs happy spitters = GER, eosinophilic esophagitis (EoE; often w/ atopy)
- ∆ position, ∆ diet
- tx: PPI
- GER tx: 30º angle laying, thicken formula w/ rice cereal


Constipation
CHOP Functional Constipation Pathway
• Red flags: concern for surgical abdomen / primary medical process / Hirschprungs / neurogenic. 
• Fecal impaction ( w/ sig pain, n/v: PR tx enemas! age based; get some BM, then PO/NG) vs no fecal impaction (PO/NG tx)
• Tx goal is clear output.
• PR Tx: enemas (glycerol, fleet Na

, NS, mineral oil), PEG
• PO/NG Tx: if >20 kg, do stimulant laxative 4hrs prior to PO/NG clean-out. then miralax or golytely, repeat until clear. 
• DC goal: 3 clears, then KUB / 2view XR.

U of Chicago: Review Constipation
U of British Columbia : Constipation

3 MC times for constipation: introduction of solid food or cow milk, toilet training, entry into school. 
Define constipation: newborn (first BM within 36 hrs), week 1 (4x/day), 3 mo (3x/day - formula 2x/day), 2-4 yo (1-2/day)
Function constipation: constipation w/o a anatomic or primary cause, most typical accounts of constipation. 

• Acute constipation tx: 5 g fiber / day via PO foods, fluids, , glycerin suppositories / mineral oil,  sorbitol containing juices (infants), miralax (>1 yo). 
• Fetal impaction: Na-phosphate enema 
• Painful defecation: mineral oil rectum, lidocaine gel 

Must r/o: Hirschprungs, spinal dysraphism, sacral teratoma, infantile botulism (infants); all agess: CF, lead poisoning, GI obstruction

Alarm signs: delayed meconium (>48hrs), F/V/diarrhea, rectal bleed (excluding anal fissure), sever abdo distension; “ribbon stools”, wt loss / poor gain, delayed growth, neuro deficits

Hirschsprungs megacolon - congenital ganglionic megacolon: 1/5k live births; need to dx early!; delayed meconium passage (>48 hrs), FTT, vomiting, abdo distension, tight anal canal w/ empty ampulla, explosive expulsion of stool w/ digital exam (squirt si). Typically dx in first few months. 

Imaging: KUB




Diarrhea: 
• 
• Stool cx. GI PCR.
• BRAT diet is no longer recommended (xs sugar, no benefit); just do regular age appropriate diet




General Fluids:
• 4ml/kg for each kg between 1-10kg +
• 2ml/kg for each kg between 11-20kg +
• 1ml/kg for each kg over 20kg
• or Quick version for over 20 kg- just add 40 to weight

• BOLUS:

• Most of time use D5 ½ NS + 10-20 meq KCl/L -
• Exceptions: NS for brain tumors; no KCl for Onc pts - ¼ NS for neonates - NS is 154 meq/L Na and Cl
• Maintenance Electrolytes : Na+: 3meq/kg/day; K+: 2meq/kg/day


PEWS System
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