PNP 2 Management Exam #1

-The cause, epidemiology of infectious or noninfectious illnesses or medical condisions, communicability issues and prevention guidelines
-The rationale for precedires involved with diagnostic testing, including laboratory, readiographic or imaging tests and the meaning of results
-Estimations of length of time before laboratory or imaging results are abilable, especially if long wating periods (frustrating for parents)
-Description of the disease, symptoms, course and signs of imprevement
-Recognition and discussion of cultural practices and beliefs about the illness and condition

-Return for any necessary follow-up or avilability for a scheduled telephone conference
-Any special treatment or therapy, use of adaptive devices, and home monitoring tests
-Proper dosing of medication, the potential need to switch medications during treatment, and side effects of both precription and OTC drugs
-Plan for administration of medications at school; completion of all appropriate forms and instruction of school personnel on key issues related to pharmacologic therapy

-Any dietary needs or changes, hydration and changes in eating patterns that can be expected
-Potential benefit or harm from specific folk medicine or complementary and alternative medicine practices if used alone or concurrently with prescribed or OTC medications
-Resources for sick care in the community that are accessible and affordable
-Safety and appropriateness of day care during the illness

-Specific signs and symptoms that indicate worsening of the illness
-The need for immediate medical attention or return visit sooner than planned

-Possible recurrence and ways to prevent spread of illness
-Determinign impediments preventing the parent of child from complying with the management plan
-Discussion about steps to correct these diffculties

-Asking them to repeat what they have been told
-Teach-back method
-Misunderstanding can be addressed

-Does not mean the drug is being prescribed improperly or unethically
-Evidence for the pharmaceutical use and safety in the pediatric age group may not have been submitted to the FDA, or the drug may not meet the "level of substantial evidence" needed for FDA approval

-Consult the Physicians Desk Reference, Epocrates or other reputable pharmacology application or the package insert
-Refer to published literature regarding a medication whenever possible. If pubulications are not available, use other scientific evidence and expert medical judgement
-Check the FDA website for any warnings about the drug
-Discuss recommendations for off-label treatment with the patient of family, document the decision-making process and the patients/families consent in the health record
-Be mindful about the precautions that come with each drug, heeding warnings and contrindications

-Relies on pain-related behaviors, typically nonverbal responses (facial expression, limb movements, and crying)
-Many toddlers use their own words to indicate pain and report its general location but cannot describe pain severeity

-Say they have "none", "a little", or "a lot" of pain and some may be able to use pain scales such as the Faces scale
-Can use words but not severity

Describe location, intensity, and quality of their pain

Provide more descriptive information

Infants/toddlers: Nonverbal behaviors
Two and three years: Can use words but not severity
Four years: Can rate the intensity of pain
Eight years: Can identify location, intensity, and quality of pain

-FLACC (Faces, Legs, Activity, Cry and Consolability)
-Wong-Baker FACES Scale and Numeric

Vocalizations:
Crying, whimpering, whining
Facial expressions:
Grimacing, tightly closed eyelids, grinding or clenching teeth
Breath-holding
Body positioning
Changes in sleep patterns (more or less)

Actions:
Rubbing or touching the painful site, avoiding the painful site, guarding the affected area, withdrawal from touch, protecting an injured limb
Social withdrawal
Vigilance
Anger

-Ask parent what word they use for pain (owie, boo-boo, ouchie, hurt)
-Self-report is the gold standard for assessment but is dependent on the child's cognitive ability to understand pain severity on a continum

-PO:
10-15 mg/kg every 4-6 hours (do not exceed 5 doses in 24 hours)
-Rectal:
10-20 mg/kg every 4-6 hours (no not exceed 5 doses in 24 hours)

-Drug of choice
-Temperature reduced by 1.8-3.6 degrees F (1-3C) within 2 hours
-15 mg/kg/dose as effective as ibuprofen at 10 mg/kg/dose

-For temperatures <102.5 degrees F (39 degrees C):
5mg/kg/dose every 6-8 hours PRN
-For temperatures >102.5 degrees F (39 degrees C):
10mg/kg/dose every 6-8 hours PRN

-Use in children 6 months old to 12 years old
-Maximum daily dose of 40mg/kg
-Temperature stays lower for a longer period of time with ibuprofen vs. acetaminophen
-Use with caution if decreased liver function, asthma, or coagulation disorder

-Also called fever without source
-Acute febrile illness in a child under 24 months of age in which the fever etiology is not apparent after careful history and physical examination

-Urinary tract infection
-Pneumonia
-Bacteremia

-Duration and degree of fever
-Any associated symptoms
-Exposures and travel history
-Vaccination status
-Neonatal history of complications
-Chronic illness
-Current medications

-For a rectal fever of 38 °C (100.4 °F) or more:
focus on the presenting illness
prenatal history and care
birth history including intrapartum fever
maternal streptococcus group B status
postnatal care

Consideration of vaccine status and recent immunizations is critical

-Should be hospitalized and receive a full septic workup
-Including a:
CBC with differential
blood cultures
catheterized urinalysis with urine culture
lumbar puncture to examine the central spinal fluid for infection and HSV
chest X-ray
stool cultures
-After completing the workup, antibiotics

-Ampicillin and cefotaxime (if meningitis concern) or gentamicin
-Add acyclovir if HSV concern and workup performed
-Add vancomycin if meningitis concern

-An infant (29 to 60 days) who is ill-appearing should be admitted with a complete workup and followed clinically as described with the newborn
-If the infant appears to be healthy with no chronic problems and was full term with an uncomplicated course postdelivery, a full septic workup may not be needed
-Management is based on the physical exam and data collected

-Ceftriaxone or cefotaxime
-Add acyclovir if HSV concern and workup performed
-Add vancomycin if meningitis concern
-Add gentamicin for broader Gram-negative coverage

-Well appearing
-Previously healthy infant
-Full term
-No focal bacteria infection
-No systemic antibiotics within 72 hours
-Negative urinalysis
-WBC >5000
-ANC <1500 bands
-Procal >0.3
-No discrete infiltrates on CXR
-Stool smear negative

-Infants 60 to 90 days, if well-appearing, should have at minimum a urinalysis and urine culture done, and possibly a CBC with differential, blood culture, and procalcitonin (PCT)
-An exception may be the infant who received immunizations within the past 24 hours and has a temperature that is below 38.6 °C (101.5 °F).

-Ceftriaxone or cefotaxime
-Add vancomycin if indicated

-Age under one-month-old
-Toxic or ill-appearing neonate, infant, or child regardless of age, risk factors, or degree of fever
-Pallor, mottled, ashen blue color
-Decreased activity (poor feeding, no smile, decreased response to stimuli, lethargy, weak, high-pitched cry)
-Tachypnea or tachycardia
-Capillary refill greater than three seconds
-Decreased urine output
-Chronic illness or underlying condition (including prematurity)
-Unreliable caretakers
-Bulging fontanel
-Nonblanching skin rash

-There is no signle marker with the necessary sensitivity, specificity, or predictive values to serve as a stand alone test upon which to initiate therapy for suspective serious infection
-Testing cannot positively confirm when to stop therapy in proven infection
-Laboratory evaluation can clarify a diagnosis or rule out a serious illness that may be under consideration
-The quality of the specimen sent to the lab strongly affects the reliability of the results (avoid skin contamination)

-Sample collection timing affects the accuracy of the results (avoid collecting sample after antibiotics have been started)
-Laboratory tests require a certain volume or quantity to ensure valid and reliable results
-Microbiologic samples may require special handling and should be transported to the lab promptly

-From an infectious disease standpoint, the WBC is the most useful piece
-WBCs can be affected by long term use of certain medications (some can decrease), age, steroid use (can increase), and clinical state (overwhelming sepsis can lead to decreased WBCs)
-Chronic inflammatory processes can cause a decrease in RBCs (anemia)

-Leukocytosis: elevated WBC
-Increase in neutrophil or polymorphonuclear cells
-Elevation in bands (immature neutrophils)

-Leukopenia: decreased WBC
-Elevated lymphocyte counts
-Atypical lymphocyte production

The platelet count is elevated (thrombocytosis) during the active phase of acute infection and correlates with concurrent elevations in CRP and ESR

-Serum acute phase reactants that increase in the presence of acute inflammation and specific pathogens
-Highly predictive of bacterial infections
-Serial testing 24 to 48 hours after the onset of symptoms are recommended and can also help monitor the body's response to treatment in certain infections

-Inflammatory processes other than infection may cause elevation:
maternal and perinatal factors
trauma
rheumatologic disease
oncologic disease
-Persistent elevation:
treatment failure
adiposity
use of birth control pills
pregnancy

-0.00 to 0.05 mg/dL
-<10 mg/dL: sepsis is less likely to happen

-Biomarker that differentiates certain viral infections from serious bacterial infections
-Rise and fall quicker than CRP during onset and control of of bacterial infections
-Valuable tool when the ability to draw a blood culture is limited
-Should only be used with other clinical and diagnostic data when making diagnostic and management decisions

-Pyelonephritis
-Pneumonia
-Early onset sepsis in premature infants
-Diarrhea associated hemolytic uremic syndrome
-Bacterial causes of acute hepatic disease
-Bacterial versus aseptic meningitis
-Posttraumatic sepsis
-Chron's disease

-Measure of inflammation and reflects RBCs settling faster when acute-phase proteins (such as fibrinogens) are present in serum than when they are not
-Not a specific test for infection
-Useful in evaluating the effectiveness of therapy when long term antibiotics are needed
-Useful in evaluating for fever of unknown origin (FUO)

-Noninfectious conditions that cause inflammation
TB
bacterial arthritis
head/neck abscess (>100 mm/h)
-Anemia causes a nonspecific increase
-ESR of >50 mm/h warrants evaluation

An ESR of <10 mm/h means a low probability of a bacterial infection

-Value of 20 mm/h
-Adenovirus causes levels of >30 mm/h

-Useful in certain clinical situations, such as when fungal or other infections are suspected
-Staining for viral infections
antigen detection immunofluorescencer or antibody assays
completement fixation tests (CFTs)
immunogluorescence techniques
enzyme-linked immunosorbent assays (ELISAs)

-Multiple organisms can be screened using one sample
-Pathogen detection
neisseria gonorrhoaea
chlamydia trachomatis
HIV
bordetella pertussis
herpesvirus
enterovirus

-Highly contagious herpesvirus
-Primary illness: chickenpox

-Direct contact
-Droplets
-Airborne

-Reactivation infection from latent varicella
-Can spread shingles to another person

10 to 21 days

-1 to 2 days before the rash erupts until all lestions crust over (about 3 to 7 days)
-Prolonged in individuals who received varicella immunoglobulin

-Not always present
-Occur 1 to 2 days before the rash phase
-Low grade fever
-Listlessness (lack of energy)
-Headache
-Backache
-Anorexia
-Mild abdominal pain
-URI symptoms

-Classic appearance
-Centripetal: begins on the scalp, face or trunk
-Pruritic lesions progress from spots to "teardrop vesicles" that cloud over and umbilicate in 24 to 48 hours
-Fever of 105 degrees
-The more severe the rash, the higher the fever
-Lesions can develop on all mucosal tissue

-Use tweezers to grasp the tick firmly at its head or mouth, next to the skin. Use a magnifying glass, if you have one, to see the tick clearly
-Pull firmly and steadily until the tick lets go of the skin. Do not twist the tick or rock it from side to side. Parts of the tick might stay in the skin, but eventually will come out on their own
-Wash your hands and the site of the bite with soap and water
-Swab the bite site with alcohol to disinfect the skin
-Never use petroleum jelly or a hot match to kill and remove a tick. These methods don't get the tick off the skin, and can make it burrow deeper and release more saliva (which makes it more likely to pass a disease)

-Occurs within 1 to 2 weeks after the bite
-Rash occurs at the innoculation site
-Erythema migrans (EM) rash begins and progresses to a "bull's-eye" and needs to be at least 5 cm to meet the diagnostic criteria

-Seconday lesion appears, that is smaller than the EM lesion
-Neurologic symptoms
frequent headaches
lethargy
neck pain
mood swings
neuralgia
parathesia
cranial neuropathies
-Cardiac symptoms
lyme carditis
presenting as syncope and malaise
-Most symptoms wax and wane during this time

-Begins with pauciarticular or monoarticular arthritis that occuws weeks to months after the initial tick bite
-Chronic neuologic symptoms occur (paresthesia in knees)
-Edematous, hot, and erythemous joints
-If left untreated, late manifestation of the disease appear months to years after the initial infection

-Several tests for IgM antibodies positive 2 to 4 weeks (4 to 6 weeks for IgG) after a bite
-Because of false-positive results, serological tests should not be routinely used for screening
-Serologically positive results may indicate prior infection rather than present acute infection because IgM antibodies do not decline until 4 to 6 months after disease onset, and IgG antibodies remains elevated for years

-First step is enzyme immunoassay (ELISA) or (rarely) indirect IFA
-If results are negative, the second step is not needed
-If the first results are positive or equivocal, a second test using an IgM and IgG Western blot for Bb antibodies is done for an individual with symptoms for less than 30 days
-If symptoms are present more than 30 days, an IgG Western blot test alone is performed
-A positive Western blot test is interpreted as reacting with 5 to 10 scored bands on the IgG assay and 2 to 3 on the IgM assay
-The number of bands necessary for confirmation of LD is controversial
-The ELISA produces many false postivies because of cross-reactions with other spirochetes, lupus, and varicella organisms
-After 4 weeks of symptoms, the IgG result should only be used to support the diagnosis

-Clinical judgement determines whether to treat the patient
-The earlier in the EM stage that treatment starts, the better long-term outcomes
-Delaying treatment until test results come back decreases chances of successful treatment

-Doxycycline
-Amoxicillin
-Cefuroxine

-Amoxicillin 50 mg/kg/day, orally, divided into 3 doses for 14 days
-Maximum of 1.5 g/day

-Doxycycline
-Single 200 mg dose daily PO for 14 days
-4 mg/kg/day divided into 2 doses PO for 14 days
-Maximum 200 mg/day
-Give snack to reduce nausea

-Cefuroxime
-30 mg/kg/day orally
-Divided into 2 doses for 14 days

-If tick was not identified as an Ixodus and the attachment timeline is not verified, then prophylaxis should not be given
Given to children when the history includes the following:
-The tick is identified as a nymph or adult I. scapularis species
-The tick was attached for 36 to 72 hours
-The tick was acquired in an epidemic area

-Start antibiotics treatment prior to the onset of the rash and within the first 5 days if other clinical symptoms suggest RMSF, especially because of possible early false-negative serology
-Without early treatment, the disease rapidly progresses to death
-If the child appears in the summer in endemic area with an acute fever of less than 2 days but without prfound malaise/mylagia/headache, obtain a CBC and chem panel and monitor the child
-If the fever progresses to the third day and lab studies suggest RMSF, or if the child appears toxic, empiric antibiotics should be started
-Conjunctivial injection and peripheal edema may appear at the same time as the rash, their presence points toward a diagnosis of RMSF

-Treatment lasts 7 to 10 days
-<100lb: 2.2 mg/kg per dose given BID PO or IV
->100lb: 100 mg BID PO or IV

-Children younger than two years of age (especially infants younger than six months)
-People 65 years old and older
-Those with chronic diseases

1 to 4 days

24 hours before the onset of symptoms

Peaks by day 3 and ceases 7 days after the onset of illness

-Sudden onset of high fever, headache, chills, coryza, vertigo, sore throat, dry hacking cough, and pain in the back and extremities
-Young children may have nausea, vomiting, diarrhea, and croup, as well as conjunctival infection and epistaxis
-Infants can become septic
-Lower respiratory tract symptoms in severe infection with atelectasis or infiltrates; may also present with severe influenza-associated myocarditis with weak heart sounds, a rapid, weak pulse, and CHF symptoms

-Rapid tests have limited sensitivity
-Viral cultures taken from the nasopharyngeal or nasal cavity within 72 hours of illness onset can confirm the diagnosis
-Other tests for influenza include a PCR

-Supportive—bed rest, OTC antipyretics, fluids
-Observe for worsening symptoms
-Viral resistance to amantadine and rimantadine—recommended not to use until reliable susceptibility
-Antiviral therapy (i.e., zanamivir, oseltamivir, or peramivir [restricted to those 18 years old or older] in the United States) should be prescribed for only:
Children with immunosuppression
Children younger than two years old
Children with chronic illnesses
Women who are pregnant or postpartum (within two weeks after delivery)
Children or adolescents who are younger than 19 years old and on long-term aspirin therapy
Native Americans/Alaska Natives
Children who are morbidly obese (i.e., BMI is 40 or greater)
Children in residential care facilities
-If antivirals are indicated, they should be started within 48 hours of symptom onset.
Complications—Reye’s syndrome, respiratory infections, acute myositis, myocarditis, asthma/CF exacerbations

2 to 5 days

Few months

-Respiratory:
peritonsillar abscess
cervical lymphadenitis
otitis media
mastoiditis
sinusitis
-Scarlett fever:
fever reaches 104 degrees
pharynx is inflammed and is covered with gray-white exudate
palate and uvula are erythematuous and reddened

-Bacteremia:
occurs after a respiratory and localized infections
-Perianal streptococcal cellulitus:
local itching
pain
blood-streaked stools
proctitis

-Antimicrobial therapy is recommeded for GABHS pharyngitis to decrease the risk of:
acute rheumatic fever
decrease the length of illness
prevent complications
reduce transmission

-Upper respiratory:
cervial lymphadenitis
retropharyngeal abscess
otitis media
mastoiditis
sinusitis
-Pediatric associated neuropsuchiatric disorders associated with streptococcal infections (PANDAS):
OCD
tic disorders
tourette syndrome

Parvovirus B19

4 to 21 days

Rash and symptoms occur between 2 and 3 weeks after exposure

Highest before the rash, joint pain, or edema

-Mild fever
-Myalgia
-Headache
-Malaise
-URI symptoms

-Occurs 7 to 10 days after the prodrome phase
-Occurs in 3 stages:
1. First appears on the face as an intense red eruption on the cheeks
2. Lacy maculopapular eruption appears on the trunk and moved peripherally to the arms, thighs, and buttocks
3. Rash subsides, but some older children have mild pruritus

-Lab testing is generally not needed
-Serum B-19 specific IGM antibody confirms the presence of the infection and persists for 6 to 8 weeks
-Anti-B19 IgG confirms past infections
-For immunocompromised individuals, PCR assay is the method of choice

-No specific antiviral treatment
-Consider treatment in:
those with hemolytic anemia
those who are immunocompremised
-IGIV helps those with immunicompromised conditions

-Human herpesvirus (HHV-6; HHV-7)
-Spread via oral, nasal, conjunctival routes

Most common in children between 7 to 24 months of age due to the waning of maternal antibodies

9 to 10 days

Greatest during the fever phase before the rash appears

-Sudden onset of fever (101 °F [38.3 °C] to more than 103 °F [93.4 °C]) for three to seven days without seeming ill
-Febrile seizures may occur as a result of a high fever
-Once the fever breaks, a diffuse, nonpruritic, discrete, rose-colored, maculopapular rash begins to form
-High fever with the development of a rash as the fever breaks is a classic picture of roseola.
-During the fever phase, children might receive a workup for fever without focus as there are typically no other specific symptoms and diagnosis is not clear until the rash appears
-The rash is blanchable (good sign)
-The rash can last from several hours to two to three days, begins on the trunk and spreads outward, and rarely coalesces

-Drain the lesion
-Send wound drainage for culture and susceptibility testing
-Advise the patient on wound care and hygeine
-Discuss follow-up plan with patient

-Presence of abscesses (one or multiple sites)
-Rapidly progressing local infection with signs of cellulitus
-Systemic symptoms
-Comobidities or immunosuppression
-Abscess in in an area difficult to incise/drain (face, hand, genitalia)
-Lack of response to incision/drainage

-Acute allergic conjunctivitis
-Seasonal allergic conjunctivitis (hay fever)
-Perennial conjunctivitis
-Vernal conjunctivitis

-Sudden onset of symptoms (within 30 minutes) after exposure to an environmental allergen such as animal dander
-Causes itching, tearing, chemosis, and eyelid edema
-Condition resolves within 24 hours once exposure to the allergen ends

-Mild conjunctival injection and swelling
-Associated with exposing the eyes to outdoor pollens and may be associated with a generalized allergic reaction, including nasal congestion
-Seasonal allergens (grass pollens, ragweed) cause 90% of the cases of allergic conjunctivitis in the United States

-Chronic conjunctivitis related to year-round exposure to allergens such as dust mites, animal dander, and molds
-Usually mild and waxes and wanes throughout the year

-More severe, with peak incidence in 10- to 12-year-olds
-Occurs in boys twice as commonly as in girls
-Increased prevalence in warm weather

-Severe itching and tearing
-Family history
-Rhinitis, eczema, asthma
-Precipitated by allergens
-Redness, swelling of conjunctiva or eyelid
-Follicular reaction
-Stringy, mucoid discharge
-Bilateral involvement
-Cobblestone papillary hypertrophy
-Normal vision screen

-Diagnosis is typically made on history and clinical findings
-If smears are obtained, they will reveal eosinophils

-Prevented by avoiding allergens
-A saline solution or artificial tears can be used for mild cases along with cool compresses
-Other management strategies include:
topical decongestants
antihistamines
Pataday to be effective.

-Known as a stye
-Infection of the sebaceous glands, eyelids, or meibomian glands

Tender, swollen furuncle

-Apply warm, moist compresses to the affected eye three or four times daily, 10 to 15 minutes each time, to facilitate spontaneous rupture
-Proper hygiene can be maintained by scrubbing the eyelashes and eyelids with a cotton-tipped applicator or clean washcloth with a weak (50%) solution of no-tears shampoo once or twice a day
-The use of an antistaphylococcal ointment (0.5% erythromycin) may also be effective
-If the hordeolum does not rupture on its own, or if the child experiences multiple or recurrent hordeolum, then a referral to pediatric ophthalmology may be required

-Commonly referred to as pink eye
-It is very contagious, spreads easily, and is most often caused by H. influenzae.

-Erythema
-Yellow–green purulent discharge
-Encrusted or matted eyelids on awakening
-Burning, stinging, itching
-Photophobia
-Petechiae on the bulbar conjunctiva
-Symptoms of URI
-Normal vision screen

-Resolves on its own within eight to 10 days
-Both Gram-negative and Gram-positive organisms can be causal factors, children who are prescribed topical antibiotics show a quicker clinical resolution of symptoms, returning to daycare or school faster and decreasing the time needed for a parent to call out of work

-Ofloxacin and moxiloxacin
-Sodium sulfacetamide 10% ophthalmic solution or ointment
-Not effective against H. influenzae, stings, and can cause allergic reactions (including Stevens-Johnson syndrome)
-Trimethoprim sulfate plus polymyxin B sulfate ophthalmic solution (Polytrim)
-Erythromycin 0.5% ophthalmic ointment for patients with a sulfa allergy
-Fluoroquinolone ophthalmic drops such as besifloxacin, ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, or ofloxacin for children older than 12 months of age

-Fever is present
-Orbital discomfort or pain, proptosis, or paralysis of the extraocular muscles points
-Bacteremia
-Unable to fully move eyes, moves head to see peripheally
-Pain with eye movement
-Visual changes
-Ptosis

-Visual acuity
-Extraocular movements
-Pupillary reaction testing
-CBC with diff
-Blood cultures
-CT to rule out sinusitus or subperiosteal abscess

Referal to opthamology

-Misalignment of eyes, in which one eye deviates towards the nose
-Occurs between 1 and 8 years of age and may occur intermittently
-Children generally have hyperopia

-Misalignment of eyes, in which one eye deviates away from the nose
-Intermittent in children 6 months to 4 years who are ill, tired,exposed to bright light or with sudden changes from close to distant vision
-It is more often seen when the child is looking with distant fixation

-Darken exam room to identify subtle asymmetries
-Look at pupils simultaneously and separately
-If any asymmetry, dark or white spots, opacities, or leukocoria are found, further investigation or referral is required
-Infants with a family history of retinoblastoma should be referred at one to six weeks of age for an ophthalmologic exam

Chlamydia

-Chlamydia trachomatis: Manifests at five to 14 days of life with moderate eyelid swelling and moderately thick, purulent discharge.
-N. gonorrhoeae: Manifests at three to five days of life with acute conjunctival inflammation, erythema, lid edema, and excessive purulent discharge.
-HSV: Manifests at birth with mild conjunctivitis, erythema, serosanguineous discharge, and a vesicular rash on the eyelid. Is most often unilateral.

-Swabs and scrapings must be done and any infant younger than two weeks of age with ophthalmia neonatorum should be tested for gonorrhea
-If gonorrhea is suspected, also check for C. trachomatis

Prophylactic erythromycin ointment 0.5% at birth

Irrigate with sterile saline after obtaining cultures until clear of exudate

IM ceftriaxone

-Topical antibiotics such as erythromycin 0.5% ointment
-Trimethoprim-polymyxin B
-Fluoroquinolone drops

-Immediate hospitalization
-Topical and systemic antivirals

-Assess for systemic infection (pharyngitis, ear infection, or pneumonia)
-Treat with systemic erythromycin (50 mg/kg/day in four divided doses for 14 days)
OR
-Azithromycin (20 mg/kg for three days)
-Topical treatment is not needed because it does not lower the risk for subsequent pneumonia

-Will resolve on its own within three to four days
-No treatment is necessary

Abnormal obstruction of the nasolacrimal duct

Inflammation of the nasolacrimal duct leading to possible infection

-Continuous or intermittent tearing; mucous discharge
-Blepharitis in lids or lashes
-Nasal obstruction or drainage
-Edema or erythema of tear sac
-Infection may occur

A complete blood count and culture of the drainage should be obtained if the case is severe. Fluorescein dye, instilled bilaterally in the inferior conjunctival sac and checked at two and five minutes with a cobalt blue light source will disappear if the duct is patent.

-Duct blockage usually resolves spontaneously in 90% of infants by six months of age and 96% of infants by 12 months of age
-Minimize stagnation with daily massage of the lacrimal sac, prevent infection
-Antibiotic ointment or drops if indicated
-Saline drops in the nose
-Refer to an ophthalmologist if persistent or severe

Damage to or loss of epithelial cells of the cornea

-Symptoms can range from mild to severe
-Sensation of/evidence of foreign body
-Severe pain/photophobia
-Tearing and blepharospasm
-Decreased vision
-Conjunctival erythema
-Fluorescent staining: to visualize tear

-Eye drop that you use and it makes the eye yellow and it will tear and yellow will run down the face
-You're going to make sure when you do the fluorescein staining that you have tissues nearby to catch that excess running down the face
-Then after it's had time to coat the eye and when the child is crying and they're blinking or even if they're older and they're not crying and they're blinking, that will coat the eye with the staining
-You're going to turn off the lights, you should have a UV blue light that goes with your kit and you just put that blue light on the eye after the stain has coated the entire eye

-Refer to opthlamology if severe or if symptoms worsen
-Topical antibiotics: 0.5% erythromycin 2 to 3 times a day for 2 to 4 days
-Prevent rubbing eyes
-Oral analgesics or ophthalamologic NSAIDs for comfort

Commonly occur in younger children during play and in older children during sports; they can include dirt, dust, or metallic particles

-If superficial they rarely result in serious trauma
-Pain, foreign body sensation
-Tearing, inflammation
-Irregular or peaked pupil
-Photophobia
-Opaque lens
-Perforating wound to cornea/iris

-Fluorescein staining can help if you are unable to see the foreign body
-Ultrasonography or CT scan may be needed, depending on the foreign body and its location.

-Never remove intraocular foreign body or if history of projectile foreign body
-Topical anesthetic to facilitate cooperation
-If not visualized, but suspected, attempt irrigation
-Irrigate if visualized
-If unable to remove, refer immediately
-Irrigate thoroughly if airbag deployed

Kids putting things in there

-Most are asymptomatic
-Bigger objects like peas or corn that can get more edematous and swollen with fluid
-Persistent cough or hiccups
-Unilateral otalgia
-Otorrhea (ear drainage)

-if you can’t get it after a few attempts, don’t be afraid to go ahead and refer to ENT
-You only want to remove it if you can see it well, if the patient is cooperative, and if you’re skilled in doing so
-Soft, irregularly shaped objects are generally graspable with a bayonet forceps, or alligator forceps, or a curved hook
-Round or breakable objects can be removed using a curette by slowly advancing on the object and then withdrawing carefully

-Irrigation if the tympanic membrane is intact (only use body temperature water)
use a 60ml syringe with an angiocatheter on the end
be aware that irrigation can push that object farther into the ear canal
avoid anything that once fluid is introduced would become larger or more swollen or edematous (organic material such as corn and peas),
avoid if the object is a disc battery, you do not want to irrigate (refer to ENT for emergent removal)

-Put mineral oil in there
-It will suffocate them and cause them to die and then you can irrigate with the fluid, whether that’s ear solution or sterile saline
-If it won’t come out, then you can go ahead and refer for removal

-Also known as swimmers ear
-Diffused inflammation of the external ear canal and it may involve the pinna and the tympanic membrane
-Aeruginosa and staph aureus are the most common bacterias that cause otitis externa
-For fungal, it’s aspergillus or candida.

-Itching and irritation
-Pain is disproportionate to what is seen on the exam
-When you go to move that pinna or if you press on the tragus, they will react very strongly with pain and will pull away from you (Key symptom)
-Pressure or fullness in the ear
-Some hearing loss
-Swollen edematous ear canal with debris
-Simple infection with edema discharge in erythema
-Furuncles or small abscesses that form in the hair follicles in the ear canal, or infection of the superficial layers of the epidermis

-Derived flaky appearance to it
-May not be experiencing fullness, but they will still have pain with that

-Cirpodez or corticosteroid ear drops (first-line treatment)
-Ear drops containing acetic acid or an antibiotic otic drop with or without corticosteroids
-You want to avoid ototoxic drops if there’s a risk of tympanic membrane perforation, so no gentamicin otic drops that would be ototoxic
-Don’t treat these people with systemic antibiotics because they don’t have systemic symptoms
-Acetaminophen or ibuprofen for pain

-System symptoms should markedly improve within seven days, but the resolution of the infection may actually take up to two weeks, and we want to use the drops until all symptoms are resolved
-Sometimes it will be so edematous and swollen that you have to slip an ear wick inside the ear canal
-You put the drops in and it’s almost like a candle wick, and it wicks or pulls that drop into the ear canal, and as it heals, that wick will fall out as the inflammation reduces
-You may have to use an ear wick if it’s so closed up that the drops would not get in there

-Want to avoid chlorine water in the ear canals
-If they have a history of otitis externa, they can use earplugs when swimming
-We can also do a mixture of alcohol—rubbing alcohol, vinegar, and distilled water, 2:1:1, three to five drops daily after swimming
-It’s going to be in that or they can even do it after bathing so that it doesn’t reoccur. So 2:1:1 of alcohol, vinegar, and distilled water
-Use a blow dryer after they’ve gone swimming on low to dry the inside of the ear canal and that will prevent the moisture from staying in there
-Avoid removing ear wax: its a protective barrier for the ear

Yes

Yes

Yes

Yes

-Provide prescription and/or wait
-Close follow up

-Provide prescription and/or wait
-Close follow up

-When evidence of middle ear effusion without signs/symptoms of acute infection
-Decreases mobility of TM/interferes with sound conduction
-May occur from:
spontaneously with eustachian tube dysfunction or by
inflammation after acute otitis media
viral illness
enlarged adenoids
barotrauma
allergies
-Fluid is not infected, it is clear

-Often asymptomatic/afebrile
-Intermittent mild ear pain
-Fullness in ear
-Hearing loss in older children
-Dizziness or impaired balance
-Chronic vomiting, FTT

-Decreased TM mobility by pneumatic otoscopy
-TM dull – bulging, opaque to retracted
-Landmarks visible or not visible
-Afebrile

-Flat tympanogram
-May have 25-31 dB hearing loss

-Three-month period of watchful waiting
-Documentation of effusion, associated symptoms
-Hearing tests
-Identification of children at risk for speech, language, learning problems (refer to ENT)
-Bilateral myringotomy (ear tubes)
-No evidence that decongestants, antibiotics, nasal steroids are of benefit
-Antihistamines may be of benefit if allergies present
-Tonsillectomy or adenoidectomy alone not useful (would only remove with OSA and OME)

-Put ear tubes in if it's persistent or its chronic with associated with hearing loss or decreased hearing
-Adenoidectomy is not indicated unless an indication exists other than just otitis media with effusion (OSA)

-Follow-up until TM/hearing normal
-Remember important role of language development
-Maximize hearing by:
facing child; get within 3 feet when speaking
enunciating clearly
using visual clues
turning off competing background noise
requesting preferential classroom seating

-Rare
-Result of a chronic ear infection
-Formation of an epidermal inclusion cyst of the middle ear

profuse purulent drainage despite antibiotics
you may see a pearly white lesion on or behind the TM

-Grows in size, it can destroy the surrounding structures
-Chronic otorrhea
-Facial muscle paralysis
-Irreversible structural damage
-Permanent bone damage
-Hearing loss
-Intracranial infection

ENT referral

-Superficial skin injuries, often from falls or friction, and result in epidermal trauma
-Rough or hard-surfaced object lacerating or scraping the skin is the most common type of injury

most serious form of abrasion, resulting in the loss of epidermal, dermal, and subcutaneous layers

-Most can be managed at home unless the abrasion is deep, involves a large area, is associated with severe pain, or has a significant amount of dirt, grime, tar, or a foreign body in the wound
-Best way to clean a minor wound is with gentle irrigation with copious amounts of cool running water or normal saline and mild soap
-Small abrasions can be left open to the air or may require a small bandage
-Larger abrasions heal quicker if kept moist and should be covered with a nonadherent bandage

-Wash abrasions at least every 24 hours and to reapply dressings and antibiotic ointments (i.e., bacitracin/polymyxin B) until a protective dry scab forms
-Tetanus prophylaxis should be given if the wound is significant or if it’s been more than five years since the child’s last tetanus immunization
-If tar is present, rub the wound area with petrolatum, and then repeat the normal saline or water irrigation
-Avoid povidone-iodine, alcohol, and hydrogen peroxide on open wounds

-First Line:
amoxicillin clavulanate for 7 to 10 days
-Alternative:
cephalexin
clindamycin

-Cover for Pasteurella multocida (cat and dog bites)
-First Line:
amoxicillin clavulanate for 7 to 10 days
-Alternative:
cefuroxime
fluoroquinolone
trimethoprim-sulfamethoxazole (TMP-SMX)
clindamycin
metronidazole

-Cover for Pseudomonas aeruginosa
-First Line:
ciprofloxacin for 7 to 20 days
-Alternative:
consult with infectious disease as it may require IV therapy

-Most wounds can be closed using primary intention as soon as possible after the injury.
-Delayed wound closure increases the risk of infection, and since children are less likely than adults to get infections, wounds can be closed more readily.
-Facial wounds can be closed up to 24 hours after injury for optimal cosmetic outcomes.
-Infection is inversely related to blood flow; the lower the blood flow to that area, the higher risk for infection (i.e., a hand or foot injury is more likely to get infected than a scalp laceration).

-Contaminated wounds, crush wounds, and wounds in children who are immunocompromised are at a high risk for infection and should be closed within six hours
-Animal and human bites should be left open to heal by secondary intention
-Delayed primary closure involves closing a wound three to five days after the initial injury when the risk of infection decreases. This is recommended for heavily contaminated wounds and those associated with extensive damage

-Irrigation preferred. 50–100 ml/cm of water or normal saline can be used
-Use a large irrigating syringe to provide force
-A chlorhexidine/iodine preparation is used only to clean the surrounding skin
-Hydrogen peroxide and alcohol are not recommended
-Explore the wound for foreign bodies, deep tissue layer damage, injury to nerves or blood vessels, or joint involvement
-Debride the wound with gentle removal of unattached tissue

-Used for simple, uncomplicated lacerations
-Absorbable sutures are used for the closure of structures deeper than the epidermis
-Nonabsorbable sutures are used to close the outermost layer of a laceration

-Used for lacerations of the scalp, trunk, and extremities
-They provide a more rapid closure and lower risk of infection but should never be used on the hands or feet -Staples can be more painful to remove and cannot be used if the patient is likely to get a CT or MRI

-Used for small, superficial wounds
-Do not use them on very small children as they will be more likely to pull it off too early.

-Used for simple lacerations with clean edges
-It is applied on top of the skin while the edges of the wound are held together
-Do not apply skin glue inside the wound
-It usually takes two or three applications to form a strong bond
-The glue will fall off as the wound heals, about 7–10 days later, and has minimal risk for infection due to its antimicrobial properties.

-Involves epidermis only
-Erythema, pain, inflammation; no blisters
-Heal in three to seven days with little scarring
-Example: sunburn

-Involves the epidermis and dermis
-Dermal appendages always preserved and are a good source for regeneration

-Red, painful, mottled, moist, blistered
-Heals in seven to 14 days and scarring may occur

-Pale, yellow; less painful, weepy
-Heals in three weeks and scarring likely

-Major thermal injuries to epidermis, dermis destroyed
-Whitish, waxy, or leathery
-Dry, nontender
-Profound fluid losses
-Usually require skin grafting and permanent scarring occurs

-Previously called fourth degree
-Destruction or extensive injury of muscle, fascia, nerves, tendons, vessels, bone
-Require surgical intervention and skin grafting

-Tetanus or rabies vaccination if indicated
-Provide analgesia, anesthesia, or both
-Debridement and irrigation to remove any foreign material
use normal saline to irrigate with high pressure and high volume (>1L)
if it’s an isolated puncture wound, do not irrigate. Instead, soak the wound in a diluted solution of tap water and povidone/iodine for 15 minutes
-3–5 days of prophylactic antibiotics for all human or cat bites and for hands and puncture bites with bone, tendon, muscle, or joint involvement

-When making the decision to suture with delayed primary closure or to allow for healing by secondary intention, consider the type, size, and depth of the wound
-Any bites involving the hand or foot should not be sutured but allowed to drain. Hand and foot bites <1.5 cm best heal by secondary intention; bites >1.5 cm should have delayed primary closure
-Any bite wounds >8 to 12 hours old should not be sutured
-For any child with a severe bite, refer to pediatric surgery
-Report any dog and wild animal bites to animal control

-Avoid stray animals
-Exercise caution around all animals
-Parental supervision when playing with pets