There are two kinds of suffering. There is the suffering you run away from, which follows you everywhere. And there is the suffering you face directly, and in doing so become free. ~ Ajahn Chah

There are two kinds of suffering. There is the suffering you run away from, which follows you everywhere. And there is the suffering you face directly, and in doing so become free. ~ Ajahn Chah 

MOST LIKELY TIME OF DTH IS 1100 , SO LIKELY AFTER BREAKFAST

NICE UTI INV

Table 8 Recommended imaging schedule for children 3 years or older

Test	Responds well to treatment within 48 hours	Atypical UTI a	Recurrent UTI a
Ultrasound during the acute infection	No	Yesb c	No
Ultrasound within 6 weeks	No	No	Yesb
DMSA 4–6 months following the acute infection	No	No	Yes
MCUG	No	No	No
a See box 1 for definition b Ultrasound in toilet-trained children should be performed with a full bladder with an estimate of bladder volume before and after micturition. c In a child with a non-E. coli-UTI, responding well to antibiotics and with no other features of atypical infection, the ultrasound can be requested on a non-urgent basis to take place within 6 weeks

FPIES described even in exclusively breast-fed infants in which symptoms occurred after maternal ingestion of cow's milk.

FPIES described even in exclusively breast-fed infants in which symptoms occurred after maternal ingestion of cow's milk.


profuse and repetitive vomiting, severe diarrhea, leading to dehydration and lethargy in infant

Elevated blood eosinophils in early infancy are predictive for atopic dermatitis in children with risk for atopy

Elevated blood eosinophils in early infancy are predictive for atopic dermatitis in children with risk for atopy

Having a relative with epilepsy may increase your risk of being diagnosed with autism

Having a relative with epilepsy may increase your risk of being diagnosed with autism

Religious service attendance linked to better cognitive and emotional well-being

Religious service attendance linked to better cognitive and emotional well-being

BRONCH=most infants discharged from the ED with bronchiolitis experienced desaturation events, and these desaturation events did not correlate with subsequent medical visits or hospitalization.

most infants discharged from the ED with bronchiolitis experienced desaturation events, and these desaturation events did not correlate with subsequent medical visits or hospitalization.

LOW FAT VS LOW CARB DIETING

Food fight

Standard plate: low fat Recommends a daily total of 2000 calories for women, 2500 calories for men. Percentages add up to 99% because of rounding

Alternative plate: high fat There is no overall daily calorie recommendation, only a recommended range of calorie intakes for each individual food group. For rough comparability with the low-fat plate, the percentages in the diagram are based on an average calorie intake from each group

Low-fat diet top tips		High-fat diet top tips
Carbs Avoid sugar Fill up on starchy carbs, especially wholegrain or higher fibre sources with less added fat, salt and sugar		Carbs Avoid sugar Limit starchy foods like bread, potatoes, rice, pasta, cereals
Fats Avoid artificial trans fats found in processed foods Choose unsaturated oils for frying and spreading and use in small amounts Limit fat as much as possible to avoid weight gain		Fats Avoid trans fats and processed, polyunsaturated vegetable oils such as sunflower, corn, soyabean Fill up on olive oil, butter, full-fat dairy and fats in meat Don’t worry about calorie counting – the diet will make you feel full and prevent overeating
Dairy and alternatives Choose lower fat and lower sugar options		Dairy and alternatives Choose full fat. Try different varieties of cheese
Protein Eat less red and processed meat Eat more beans and pulses		Protein Try to have grass fed cattle and free range eggs
Fruit and veg Eat at least 5 portions of a variety of fruit and vegetables every day		Fruit and veg Eat a mixture of fruit, vegetables and salad, at least 400g/day

An increase in exercise was associated with a decrease in cardiovascular events, the leading cause of death in women with nonmetastatic breast cancer.

An increase in exercise was associated with a decrease in cardiovascular events, the leading cause of death in women with nonmetastatic breast cancer.

Elders who were alive 30 days after hospitalization for sepsis had significant excess risk for death during the next 2 years.

Elders who were alive 30 days after hospitalization for sepsis had significant excess risk for death during the next 2 years.

APOPHENIA

PATTERNICITY

"Our character is what we do when we think no one is looking."BROWN

"Our character is what we do when we think no one is looking."

A PLAN COME TO FRUITION, A DREAM COME TRUE

WHITE RABBIT X REALITY

QNTM THEORY PLANCK 1900

QFOV=COSMIC BURP

REBEL

INTENTION

COLLUSION IS NO LONGER AN ILLUSION

DET X FW

FW X DET

FREE WILL X HARD DET

RECI DET

HARD DETERMINISM

HUXLEY=Experience is not what happens to a man; it is what a man does with what happens to him.”

Experience is not what happens to a man; it is what a man does with what happens to him.”

REALITY X BRAIN IN A VAT

BODY X MIND

KNWLDGE

NAGEL X BAT

Let your life lightly dance on the edges of Time like dew on the tip of a leaf." -- Rabindranath Tagore

Let your life lightly dance on the edges of Time like dew on the tip of a leaf." 

-- Rabindranath Tagore 

WORLD IS IN BIG MALAISE RIGHT NOW

CONSTIPN

SHOCK

C-ADR

H-FLUIDS

O-INTERVENE

D-NORAD

DHINA HAS MOST NEIGHBOURS-14 COUNTRIES

DHINA HAS MOST NEIGHBOURS-14 COUNTRIES

UNDIFF SHOCK PEDS

 LOOK AT 4 THINGS-heart rate, volume status, contractility, and systemic vascular resistance.=
RVCR

How FAST you FILL the PUMP and SQUEEZE=RVCR

heart rate — how FAST?

heart rate – is it sinus?  Could this be a supraventricular tachycardia that does not allow for enough diastolic filling, leading to poor cardiac output?  If so, use 1 J/kg to synchronize cardiovert.  Conversely, is the heart rate too slow – even if the stroke volume is sufficient, if there is severe bradycardia, then cardiac output  — which is in liters/min – is decreased.  Chemically pace with atropine, 0.01 mg/kg up to 0.5 mg, or use transcutaneous pacing.

If the heart rate is what is causing the shock, address that first.

 at volume status.

How FAST you FILL the PUMP and SQUEEZE

Look to FILL the tank if necessary.  Does the patient appear volume depleted?  Try a standard bolus – if this improves his status, you are on the right track.

Look at contractility.

How FAST you FILL the PUMP and SQUEEZE

Is there a problem with the PUMP?  That is, with contractility?  Is this in an infarction, an infection, a poisoning?  Look for signs of cardiac congestion on physical exam.  Put the probe on the patient’s chest, and look for effusion.  Look to see if there is mild, moderate, or severe decrease in cardiac contractility.  If this is cardiogenic shock – a problem with the pump itself.  Begin pressors.

 look to the peripheral vascular resistance.

How FAST you FILL the PUMP and SQUEEZE

Is there a problem with systemic vascular resistance – the SQUEEZE?

pediatric sepsis, the most common type is cold shock – use epinephrine (adrenaline) to get that heart to increase the cardiac output. In adolescents and adults, they more often present in warm shock, use norepinephrine (noradrenaline) for its peripheral squeeze to counteract this distributive type of shock.

• Epinephrine for cardiogenic shock
• Intervention for obstructive shock
• Fluids for hypovolemic shock
• Norepinephrine for distributive shock

DISTRIB SHOCK PED S-SEPSIS C

Distributive Shock

The most common cause of distributive shock is sepsis, followed by anaphylactic, toxicologic, adrenal, and neurogenic causes.  Septic shock is multifactorial, with hypovolemic, cardiogenic, and distributive components.

Children with sepsis come in two varieties: warm shock and cold shock.

Distributive Shock: Act

Warm shock is due to peripheral vascular dilation, and is best treated with norepinephrine.

Cold shock is due to a child’s extreme vasoconstriction in an attempt to compensate.  Cold shock is the most common presentation in pediatric septic shock, and is treated with epinephrine.

hVOL SHOCK PEDS

Hypovolemic Shock

The most common presentation of pediatric shock; look for decreased activity, decreased urine output, absence of tears, dry mucous membranes, sunken fontanelle.  May be due to obvious GI losses or simply poor intake.

Rapid reversal of hypovolemic shock: may need multiple sequential boluses of isotonic solutions. Use 10 mL/kg in neonates and young infants, and 20 mL/kg thereafter.

Hypovolemic Shock: Act

Tip: in infants, use pre-filled sterile flushes to push fluids quickly.  In older children, use a 3-way stop cock in line with your fluids and a 30 mL syringe to “pull” fluids, turn the stopcock, and “push them into the patient.

Titrate to signs of perfusion, such as an improvement in mental status, heart rate, capillary refill, and urine output.

When concerned about balancing between osmolality, acid-base status, and volume status, volume always wins.  Our kidneys are smarter than we are, but they need to be perfused first.

 

OBS SHOCK PEDS

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Approach to Shock

Updated on June 1, 2016 By thoreczko 0 Comments

Do we recognize shock early enough?

How do we prioritize our interventions?

Are we making our patient better or worse?

World wide, shock is a leading cause of morbidity and mortality in children, mostly for failure to recognize or to treat adequately.

So, what is shock?

Simply put, shock is the inadequate delivery of oxygen to your tissues.  That’s it.  Our main focus is on improving our patient’s perfusion.

Oxygen delivery to the tissues depends on cardiac output, hemoglobin concentration, the oxygensaturation of the hemoglobin you have, and the environmental partial pressure of oxygen.

At the bedside, we can measure some of these things, directly or indirectly.  Did you notice, however, that blood pressure is not part of the equation?  The reason for that is that blood pressure is really an indirect proxy for perfusion – it’s not necessary the ultimate goal.

The equation here is a formality:

DO2 = (cardiac output) x [(hemoglobin concentration) x SaO2 x 1.39] + (PaO2  x 0.003)

 

Shock CAN be associated with a low blood pressure,

but shock is not DEFINED by a low blood pressure.

 

Compensated Shock: tachycardia with poor perfusion.  A child compensates for low cardiac output with tachycardia and a increase in systemic vascular resistance.

 

Decompensated Shock: frank hypotension, an ominous, pre-arrest phenomenon.

 

Shock is multifactorial, but we need to identify a primary cause to prioritize interventions.

 

How they “COHDe”: Cardiogenic, Obstructive, Hypovolemic, and Distributive.

 

Cardiogenic Shock

All will present with tachycardia out of proportion to exam, and sometimes with unexplained belly pain, usually due to hepatic congestion.  The typical scenario in myocarditis is a precipitous decline after what seemed like a run-of-the-mill URI.

Cardiogenic shock in children can be from congenital heart disease or from acquired etiologies, such as myocarditis.  Children, like adults, present in cardiogenic shock in any four of the following combinations: warm, cold, wet, or dry.

“Warm and Dry”

A child with heart failure is “warm and dry” when he has heart failure signs (weight gain, mild hepatomegaly), but has enough forward flow that he has not developed pulmonary venous congestion.  A warm and dry presentation is typically early in the course, and presents with tachycardia only.

“Warm and Wet”

If he worsens, he becomes “warm and wet” with pulmonary congestion – you’ll hear crackles and seesome respiratory distress.  Infants with a “warm and wet” cardiac presentation sometimes show sacral edema – it is their dependent region, equivalent to peripheral edema as we see in adults with right-sided failure.

“Warm” patients – both warm and dry and warm and wet — typically have had a slower onset of their symptoms, and time to compensate partially. Cool patients are much sicker.

“Cold and Dry”

A patient with poor cardiac output; he is doing everything he can to compensate with increased peripheral vascular resistance, which will only worsen forward flow.  Children who have a “cold and dry” cardiac presentation may have oliguria, and are often very ill appearing, with altered mental status.

“Cold and Wet”

The sickest of the group, this patient is so clamped down peripherally that it is now hindering forward flow, causing acute congestion, and pulmonary venous back-up.  You will see cool, mottled extremities.

Cardiogenic Shock: Act

Use point-of-care cardiac ultrasound:

Good Squeeze? M-mode to measure fractional shortening of the myocardium or anterior mitral leaflet excursion.

Pericardial Effusion? Get ready to aspirate.

Ventricle Size? Collapsed, dilated, or normal.

Careful with fluids — patients in cardiogenic shock may need small aliquots, but go quickly to a pressor to support perfusion.

Pressor of choice: epinephrine, continuous IV infusion: 0.1 to 1 mcg/kg/minute.  The usual adult starting range will end up being 1 to 10 mcg/min.

Avoid norepinephrine, as it increases systemic vascular resistance, may affect afterload.

Just say no to dopamine: increased mortality when compared to epinephrine.

 

Obstructive Shock

Mostly one of two entities: pulmonary embolism or cardiac tamponade.

Pulmonary embolism in children is uncommon – when children have PE, there is almost always a reason for it – it just does not happen in normal, healthy children without risk factors.

Children with PE will either have a major thrombophilic comorbidity, or they are NEAR ADULT teenage girls on estrogen therapy.

Tamponade — can be infectious, rheumotologic, oncologic, or traumatic.  It’s seen easily enough on point of care ultrasound.  If there is non-traumatic tamponade physiology, get that spinal needle and get to aspirating.

Obstructive Shock: Act

Pulmonary embolism (PE) with overt shock: thrombolyse; otherwise controversial.  PE with symptoms: heparin.

Tamponade: if any sign of shock, pericardiocentesis, preferentially ultrasound-guided.

ALPHABET SOUP OF KHADI HROUPS

CARDIOGNC SHOCK PEDS

Cardiogenic Shock

All will present with tachycardia out of proportion to exam, and sometimes with unexplained belly pain, usually due to hepatic congestion.  The typical scenario in myocarditis is a precipitous decline after what seemed like a run-of-the-mill URI.

Cardiogenic shock in children can be from congenital heart disease or from acquired etiologies, such as myocarditis.  Children, like adults, present in cardiogenic shock in any four of the following combinations: warm, cold, wet, or dry.

“Warm and Dry”

A child with heart failure is “warm and dry” when he has heart failure signs (weight gain, mild hepatomegaly), but has enough forward flow that he has not developed pulmonary venous congestion.  A warm and dry presentation is typically early in the course, and presents with tachycardia only.

“Warm and Wet”

If he worsens, he becomes “warm and wet” with pulmonary congestion – you’ll hear crackles and seesome respiratory distress.  Infants with a “warm and wet” cardiac presentation sometimes show sacral edema – it is their dependent region, equivalent to peripheral edema as we see in adults with right-sided failure.

“Warm” patients – both warm and dry and warm and wet — typically have had a slower onset of their symptoms, and time to compensate partially. Cool patients are much sicker.

“Cold and Dry”

A patient with poor cardiac output; he is doing everything he can to compensate with increased peripheral vascular resistance, which will only worsen forward flow.  Children who have a “cold and dry” cardiac presentation may have oliguria, and are often very ill appearing, with altered mental status.

“Cold and Wet”

The sickest of the group, this patient is so clamped down peripherally that it is now hindering forward flow, causing acute congestion, and pulmonary venous back-up.  You will see cool, mottled extremities.

Cardiogenic Shock: Act

Use point-of-care cardiac ultrasound:

Good Squeeze? M-mode to measure fractional shortening of the myocardium or anterior mitral leaflet excursion.

Pericardial Effusion? Get ready to aspirate.

Ventricle Size? Collapsed, dilated, or normal.

Careful with fluids — patients in cardiogenic shock may need small aliquots, but go quickly to a pressor to support perfusion.

Pressor of choice: epinephrine, continuous IV infusion: 0.1 to 1 mcg/kg/minute.  The usual adult starting range will end up being 1 to 10 mcg/min.

Avoid norepinephrine, as it increases systemic vascular resistance, may affect afterload.

Just say no to dopamine: increased mortality when compared to epinephrine.