Pediatrics (week 10): tongue tied and ped emergencies
final exam next week this time worth 60% of grade
short answer format they give partial credit for almost answers
covers week 5-10
TONGUE TIED
diagnosis du jour: more recognized, mb overdxd
babies need to be able to stick out tongue past lip to breast feed
breast feeding rates on the increase in the US
lingual frenulum too short-->tethers tongue down or back
severe tongue tied tongue may look heart shaped, or snaky
tx: snip the frenulum, she uses little sharp scissors and one snip, just the front 1/2 or so
kid is screaming because hand is in mouth and you're holding their head
a little pain with snip
they gen stop screaming soon as you take your hand out of their mouth
hand baby to mom and baby nurses, better right away (minutes)
downsides of snip: risk of bleeding, scarring, cut too far
if you don't want to do this tx, ENTs will do it
PEDIATRIC EMERGENCIES
HEAD TRAUMA
get hx, loc, current condition, vomiting, balance/coordination, headache, slurred speech, energy?
if no sx of neuro injury let child sleep
refer if: altered loc or unconscious >1min, persistent v, lethargy >30mins, blood from ear, other neuro sx
PE: swelling under skin is instant and superficial, spongy where skull should be mb fx
Imaging: only if neuro sx, xray, CT
TX: reassure, ice, tell pts what to watch for
Homeop: arnica for acute, nat sulph for concuss
TRAUMA TO NOSE // REPEATED NOSEBLEEDS
ddx: digital trauma, dry winter air, foreign body, viral URI, bacterial, leukemia, clot prob
examine if unreasonable pain, bony deformity, bleeding >20mins
f/u is persistent nasal swelling, difficulty breathing, refer to ENT if necc
TX: stop bleeding using pressure, ice, cauterize with silver nitrate
Tx: if kid has no sx of clotting probs then reassure, no other followup
Imaging: No indication in children under 2 years old as their noses are mostly cartilage, fx unlikely.
Can wait on x-rays. Many surgeons prefer to correct nasal fx 2-3 wks after the swelling down
Tx: to decr freq of nosebleeds, incr humidity in home, reduce trauma, don't let kids fight/pick scabs
Tx: snort powdered achillea suggested by student for acute
Tx: incr bioflavonoids, vit C, berries, veggies
Tx: order coag profile if worried about clotting
EYE TRAUMA
Okay to allow ½ hour to see if symptoms disappear screens out most minor problems
Concerning if: persistent redness/tearing, severe pain >30mins, not PERRLA, penetrating injury
Tx: if foreign body or toxin, irrigate, ice, solution with calendula or euphrasia
Homeop: euph for fb, arnica/symphytum for bruising around eye, ledum if pain after arnica and better cold
If kid gets black eye, tell parents where swelling will go, impact to orbital ridge-->swelling below eye
LACERATIONS
bad if gaping or >3/4", if persistent bleeding or pain, nerve or tendon involvement
Tx: rarely indicated to suture within mouth, only if tooth all the way through lip
Tx: stop bleeding, clean well, steri strips?, cover with clean dressing, tetanus toxoid vaccine if due
Homeop: arnica, staphysagria cutting pn, ledum wound feels numb and cold better cold, hypericum if shooting
PUNCTURE WOUNDS
concern if lesion >1/8", sev pn, f/u if incr pn, red, swell
Tx: wash, remove fb if poss, tet, consider oral abx
Homeop: ledum 200C for pn, hypericum shooting
ANIMAL BITES
examine immed if laceration >3/4", persistent bleed, unprovoked bite by dog/bat/skunk/raccoon/fox/monkey
examine later for incr red, pn, swell, bite by apparently healthy domestic animal that can't be located or hasn't been immunized vs rabies, or if not sure what happened
dog bite tx more like routine laceration or puncture, cat bite more concerning, more infx, more px
Tx for cat bites: tx with abx prophyllactically, bites on hand are esp damaging
(note from self: cats also carry fungal pathogens so tx for that also if bite into joint, can cause arthritis)
Tx: wash well, consider calendula and hypericum rinses, stop bleeding, ice, tet
Tx: if suspect rabies refer for tx and notify police
Homeop: hypericum
Assess Rabies risk: more if bite was unprovoked, animal is sick, animal of species listed above
(note from self: bat is primary carrier in OR, skunk in AZ)
less risk: rodent bite
BURNS
examine immed if burn area >3" diameter
Tx: clean well, cool compress, clean dressing, oral analgesics if necc
My tx: olive oil and aloe, alternating, cover, frozen water bottle to burn for pain
Some docs: topical abx, oral abx for 2ndary infx
Homeop: arnica followed by cantharis, urtica for stinging pain, kali bich for ulcerated second degree burns, hepar sulph for infected burns, causticum for painful burn scars
Tx: herbs: aloe vera, calendula succus, comfrey gel
POISONING
parents call
what did they take, how much, how long ago, what sx, smell like solvent?
if toxic refer fast
Tx: induce vomiting immed c ipecac (20 mins to emesis)
unless smells like solvent, then dilute w lots of h2o, watch for wheeze/cough developing 24hrs later
Examine immed if ingested CNS depressant, toxin, caustic, sig sx
Tx: i.Induce vomiting with ipecac unless the child ingested a solvent. Time from ingestion to emesis is roughly 20 minutes.
Tx: Call poison control center for advice (503) 279-8968
MC meds:
--aspirin (acetylsalicylic acid) toxic dose is 65mg per 2 pounds body weight
--tylenol (acetaminophen) toxic dose is 65mg per 2 pounds body weight, sx 2-3 days after ingest
--vitamins, eval immed if Fe containing
CHILD DOSAGES
Acetaminophen 10-15mg/kg repeated every 4-6 hours
Infant drops 80/0.8cc
Children’s syrup 160mg/5cc
Ibuprofin 5-10 mg/kg/dose repeated every 6 hours
Diphenhydramine (Benadryl) 5 mg/kg per day in 3 or 4 divided doses
DETERMINING DOSAGES
Meds for children are generally liquid and are based on the child’s weight
Convert weight in pounds to weight in kg
Multiply weight in kg by dosage in mg
If daily dose, divide by number of doses daily
Determine strength of medication
Determine how many cc’s of med per dose and how many repetitions daily
EX: Parent calls with a 10 month old male with a fever of 103.5F and screaming in pain. Parent is desiring dosage for both Tylenol. The child weighs roughly 20 pounds.-->Wt in kg (20lbs/2.2= 9.1kg), Dosage range for acetaminophen is 10-15 mg/kg so: 1.9.1kg x 10 mg/kg = 91mg per dose AND 2.9.1 x 15 mg/kg= 136mg per dose, so dosage range is 91-136mg per dose.
Next determine str of med: Parent have infant drops that are 80mg/0.8 cc
So, dosage range is 0.9cc-1.3cc per dose
Because fever is high, would likely recommend the top end of the range, so recommend 1.2cc per dose
Homeop dosing for kids
she tends toward higher potency, uses 200c's
for acutes doses ev 15 mins for up to 1 hour, then take a few hours off, then you can try again
"with repeats it works better"
if cham works with one dose don't repeat
under 6mo she uses liquid, over that can use pellets
make liquid by putting pellets in water
Bot meds
uses glycerites
or mixes ensure with tincture
teas: quantity can be an issue
chewables may taste bad or be hard to chew, not contain much med, she's skeptical, look at quality
open capsule and dump into food: quercetin for allergies, bitter, put in yog or juice concentrate or honey
tinctures: 30 drops for 3 and under, 2 droppers age 4 and up, immune and cough tinctures
short answer format they give partial credit for almost answers
covers week 5-10
TONGUE TIED
diagnosis du jour: more recognized, mb overdxd
babies need to be able to stick out tongue past lip to breast feed
breast feeding rates on the increase in the US
lingual frenulum too short-->tethers tongue down or back
severe tongue tied tongue may look heart shaped, or snaky
tx: snip the frenulum, she uses little sharp scissors and one snip, just the front 1/2 or so
kid is screaming because hand is in mouth and you're holding their head
a little pain with snip
they gen stop screaming soon as you take your hand out of their mouth
hand baby to mom and baby nurses, better right away (minutes)
downsides of snip: risk of bleeding, scarring, cut too far
if you don't want to do this tx, ENTs will do it
PEDIATRIC EMERGENCIES
HEAD TRAUMA
get hx, loc, current condition, vomiting, balance/coordination, headache, slurred speech, energy?
if no sx of neuro injury let child sleep
refer if: altered loc or unconscious >1min, persistent v, lethargy >30mins, blood from ear, other neuro sx
PE: swelling under skin is instant and superficial, spongy where skull should be mb fx
Imaging: only if neuro sx, xray, CT
TX: reassure, ice, tell pts what to watch for
Homeop: arnica for acute, nat sulph for concuss
TRAUMA TO NOSE // REPEATED NOSEBLEEDS
ddx: digital trauma, dry winter air, foreign body, viral URI, bacterial, leukemia, clot prob
examine if unreasonable pain, bony deformity, bleeding >20mins
f/u is persistent nasal swelling, difficulty breathing, refer to ENT if necc
TX: stop bleeding using pressure, ice, cauterize with silver nitrate
Tx: if kid has no sx of clotting probs then reassure, no other followup
Imaging: No indication in children under 2 years old as their noses are mostly cartilage, fx unlikely.
Can wait on x-rays. Many surgeons prefer to correct nasal fx 2-3 wks after the swelling down
Tx: to decr freq of nosebleeds, incr humidity in home, reduce trauma, don't let kids fight/pick scabs
Tx: snort powdered achillea suggested by student for acute
Tx: incr bioflavonoids, vit C, berries, veggies
Tx: order coag profile if worried about clotting
EYE TRAUMA
Okay to allow ½ hour to see if symptoms disappear screens out most minor problems
Concerning if: persistent redness/tearing, severe pain >30mins, not PERRLA, penetrating injury
Tx: if foreign body or toxin, irrigate, ice, solution with calendula or euphrasia
Homeop: euph for fb, arnica/symphytum for bruising around eye, ledum if pain after arnica and better cold
If kid gets black eye, tell parents where swelling will go, impact to orbital ridge-->swelling below eye
LACERATIONS
bad if gaping or >3/4", if persistent bleeding or pain, nerve or tendon involvement
Tx: rarely indicated to suture within mouth, only if tooth all the way through lip
Tx: stop bleeding, clean well, steri strips?, cover with clean dressing, tetanus toxoid vaccine if due
Homeop: arnica, staphysagria cutting pn, ledum wound feels numb and cold better cold, hypericum if shooting
PUNCTURE WOUNDS
concern if lesion >1/8", sev pn, f/u if incr pn, red, swell
Tx: wash, remove fb if poss, tet, consider oral abx
Homeop: ledum 200C for pn, hypericum shooting
ANIMAL BITES
examine immed if laceration >3/4", persistent bleed, unprovoked bite by dog/bat/skunk/raccoon/fox/monkey
examine later for incr red, pn, swell, bite by apparently healthy domestic animal that can't be located or hasn't been immunized vs rabies, or if not sure what happened
dog bite tx more like routine laceration or puncture, cat bite more concerning, more infx, more px
Tx for cat bites: tx with abx prophyllactically, bites on hand are esp damaging
(note from self: cats also carry fungal pathogens so tx for that also if bite into joint, can cause arthritis)
Tx: wash well, consider calendula and hypericum rinses, stop bleeding, ice, tet
Tx: if suspect rabies refer for tx and notify police
Homeop: hypericum
Assess Rabies risk: more if bite was unprovoked, animal is sick, animal of species listed above
(note from self: bat is primary carrier in OR, skunk in AZ)
less risk: rodent bite
BURNS
examine immed if burn area >3" diameter
Tx: clean well, cool compress, clean dressing, oral analgesics if necc
My tx: olive oil and aloe, alternating, cover, frozen water bottle to burn for pain
Some docs: topical abx, oral abx for 2ndary infx
Homeop: arnica followed by cantharis, urtica for stinging pain, kali bich for ulcerated second degree burns, hepar sulph for infected burns, causticum for painful burn scars
Tx: herbs: aloe vera, calendula succus, comfrey gel
POISONING
parents call
what did they take, how much, how long ago, what sx, smell like solvent?
if toxic refer fast
Tx: induce vomiting immed c ipecac (20 mins to emesis)
unless smells like solvent, then dilute w lots of h2o, watch for wheeze/cough developing 24hrs later
Examine immed if ingested CNS depressant, toxin, caustic, sig sx
Tx: i.Induce vomiting with ipecac unless the child ingested a solvent. Time from ingestion to emesis is roughly 20 minutes.
Tx: Call poison control center for advice (503) 279-8968
MC meds:
--aspirin (acetylsalicylic acid) toxic dose is 65mg per 2 pounds body weight
--tylenol (acetaminophen) toxic dose is 65mg per 2 pounds body weight, sx 2-3 days after ingest
--vitamins, eval immed if Fe containing
CHILD DOSAGES
Acetaminophen 10-15mg/kg repeated every 4-6 hours
Infant drops 80/0.8cc
Children’s syrup 160mg/5cc
Ibuprofin 5-10 mg/kg/dose repeated every 6 hours
Diphenhydramine (Benadryl) 5 mg/kg per day in 3 or 4 divided doses
DETERMINING DOSAGES
Meds for children are generally liquid and are based on the child’s weight
Convert weight in pounds to weight in kg
Multiply weight in kg by dosage in mg
If daily dose, divide by number of doses daily
Determine strength of medication
Determine how many cc’s of med per dose and how many repetitions daily
EX: Parent calls with a 10 month old male with a fever of 103.5F and screaming in pain. Parent is desiring dosage for both Tylenol. The child weighs roughly 20 pounds.-->Wt in kg (20lbs/2.2= 9.1kg), Dosage range for acetaminophen is 10-15 mg/kg so: 1.9.1kg x 10 mg/kg = 91mg per dose AND 2.9.1 x 15 mg/kg= 136mg per dose, so dosage range is 91-136mg per dose.
Next determine str of med: Parent have infant drops that are 80mg/0.8 cc
So, dosage range is 0.9cc-1.3cc per dose
Because fever is high, would likely recommend the top end of the range, so recommend 1.2cc per dose
Homeop dosing for kids
she tends toward higher potency, uses 200c's
for acutes doses ev 15 mins for up to 1 hour, then take a few hours off, then you can try again
"with repeats it works better"
if cham works with one dose don't repeat
under 6mo she uses liquid, over that can use pellets
make liquid by putting pellets in water
Bot meds
uses glycerites
or mixes ensure with tincture
teas: quantity can be an issue
chewables may taste bad or be hard to chew, not contain much med, she's skeptical, look at quality
open capsule and dump into food: quercetin for allergies, bitter, put in yog or juice concentrate or honey
tinctures: 30 drops for 3 and under, 2 droppers age 4 and up, immune and cough tinctures