PEDs Final weeks 8 - 10

Luekmia

• A type of cancer that affects blood and bone marrow, characterized by an overproduction of abnormal white blood cells.

What is the most common form of leukemia in children?

The most common form of leukemia in children is Acute Lymphoblastic Leukemia (ALL)

How do we diagnose leukemia?

• CBC → increase WBC

• decrease HBG decrease HCT

• Decrease PLT

• Blood Smear → may show increase in Blast cells

• Bone Marrow → may show increase in blast cells

what Age do we see ALL ? 2-3 years

what are the risk factors for ALL ?

• Genetic predispositions (e.g., Down syndrome, Li-Fraumeni syndrome)

• Exposure to radiation or certain chemicals (e.g., benzene)

• Previous chemotherapy or radiation therapy for other cancers

• Viral infections (e.g., Epstein-Barr virus)

What are the clinical manifestations for leukemia? pale, febrile, irritable, anorexia, hepatosplenomegaly, and lymphadenopathy

What are the consequences of bone marrow infiltration?

• anemia → from decreased erythrocyte production, leading to fatigue and weakness.

• infection → from neutropenia

• bleeding → from decreased PLT production , resulting in an increased risk of bruising and prolonged bleeding times.

what is the treatment for Leukemia ? The treatment for leukemia typically involves chemotherapy, targeted therapy, radiation therapy, and in some cases & Bone marrow transplant.

Lymphoma

What is it? Lymphoma is a type of cancer that originates in the lymphatic system, which is part of the body's immune system, and can present in various forms, including Hodgkin's lymphoma and non-Hodgkin's lymphoma.

Hodgkins Lymphoma

• Hodgkin's lymphoma: Characterized by the presence of Reed-Sternberg cells, it often presents with symptoms such as swollen lymph nodes, fever, and night sweats. Treatment options may include chemotherapy, radiation therapy, and stem cell transplant.

what are s/s of hodgkins lymphoma ? The signs and symptoms (s/s) of Hodgkin's lymphoma include:

• Swollen lymph nodes in the neck, armpits, or groin

• Unexplained weight loss

• Persistent fever

• Drenching night sweats

• Fatigue that doesn't go away

• Itching skin

• Chest pain or pressure, especially if the lymph nodes in the chest are affected.

what is the diagnosis for Non Hodgkins lymphoma?

• CBC

• chem panel with albumin

• erythrocyte sed rate

• imaging studies (CT scan or PET scan) to assess the extent of the disease and identify any lymph node involvement.

what virus is thought to cause Hodgkins Lymphoma ? The Epstein-Barr virus (EBV)

what age is hodgkins lymphoma seen in for peds ? adolescents 15-19 years of age

what gender is HL more common in ? Males

where is the lymph nodes that are commonly enlarged,firm and non tender ? supraclavicular & cervical area

what is Non Hodgkins Lymphoma ? Non-Hodgkin's Lymphoma (NHL) is a diverse group of blood cancers that includes any lymphoma except Hodgkin's Lymphoma, often characterized by the uncontrolled growth of lymphoid cells and can occur in various parts of the body, including lymph nodes, spleen, and bone marrow.

what is the risk factors for Non Hodgkins lymphoma ? The risk factors for Non-Hodgkin's Lymphoma include:

• Family history: A family history of lymphoma increases risk

• Autoimmune diseases: Conditions such as rheumatoid arthritis or lupus

• Infections: Certain viral infections such as Epstein-Barr virus or HIV

• Chemical exposure: Exposure to pesticides and solvents may raise the risk.

Osteosarcoma

• the most common bone tumor

Where do we see osteosarcomas? distal metaphyseal region

what are the diagnostic testing for osteosarcoma ? Common diagnostic tests for osteosarcoma include:

• X-rays: to identify the presence and location of the tumor

• MRI: to assess the extent of the tumor and involvement of surrounding tissues

• CT scans: to check for metastasis in lungs and other organs

• Bone biopsy: to confirm the diagnosis by analyzing the tumor tissue.

what are the manifestations of osteoscarcoma ?

• localized pain in affective site

• palpable mass

what is the drug treatment for osteosarcoma ?

• cisplatin

• doxorubicin

• methotrexate with citovorum e, which is often used in combination with other chemotherapy agents to enhance the efficacy of treatment.

Ewings Sarcoma

what is ewings sarcoma ? Ewing's sarcoma is a rare and aggressive type of bone cancer that primarily affects children and young adults, typically occurring in the pelvis, legs, or arms.

what age does ewings sarcoma happen in ? under 30

where is the most common aeras for Ewing? pelvis, long bones of lower extremities & chest wall

where does Ewings orignate ? long shaft bones in the marrow

Wilms Tumor

• also known as Nephroblastoma

• Typically occurs in children, often presenting as a palpable abdominal mass. It is associated with genetic mutations and can affect kidney function if left untreated.

what is the blood brain barrier ?

• The blood-brain barrier is a selective permeability barrier that separates the circulating blood from the brain and extracellular fluid in the central nervous system, protecting the brain from potentially harmful substances while allowing essential nutrients to pass through.

what is cerebal edema ? Cerebral edema is the accumulation of excess fluid in the brain, leading to increased intracranial pressure and potentially causing neurological dysfunction. It can result from various conditions, including trauma, infection, or stroke, and may require medical intervention to manage the underlying cause and alleviate symptoms.

what is layer of the meninges is the CSF ? The cerebrospinal fluid (CSF) is located in the subarachnoid space, which is the layer of the meninges situated between the arachnoid mater and the pia mater, providing cushioning and protection to the brain and spinal cord.

What are the causes of cerebral edema?

• meningitis

• encephalitis

• vascular insult

• Anoxic & ischemic episodes

what are early signs of a head injury in infants ?

• Unusual irritability or fussiness

• Difficulty feeding or sucking

• Changes in sleeping patterns

• Vomiting or lethargy

• Seizures or convulsions

• Bulging fontanelle (soft spot on the head)

what are nursing interventions to decrease ICP ?

• Position the patient with the head elevated at 30 degrees to promote venous drainage.

• Administer medications as prescribed, such as osmotic diuretics (e.g., mannitol) to reduce cerebral edema.

• Monitor vital signs closely, ensuring to observe for any changes in neurological status.

• Maintain a calm environment to decrease stimuli that can exacerbate intracranial pressure.

• Implement seizure precautions to ensure patient safety.

• avoid coughing,blowing nose

what is brain herniation ? Brain herniation is a serious condition that occurs when brain tissue, blood, or cerebrospinal fluid shifts from its normal position within the skull, often due to increased intracranial pressure. This displacement can compress vital brain structures and lead to severe neurological impairment or death if not promptly addressed.

what are s/s of brain herniation ?

• Common signs and symptoms of brain herniation include:

  • Altered level of consciousness (confusion, drowsiness, or coma)

  • Severe headache

  • Nausea and vomiting

  • Changes in pupil size or reaction to light

  • Weakness or paralysis on one side of the body

  • Abnormal posturing (decerebrate or decorticate)

  • Seizures

  • Respiratory irregularities

  • Loss of reflexes.

what are late signs of head injury in infants ?

• abnormal pupillary reponse

• bradycardia

• HTN

• decrease motor response

• cheyne stokes respiration

• abnormal posturing

why do we want to minimize suctioning in Decrease ICP ? Minimizing suctioning in cases of decreased ICP is crucial because excessive suctioning can lead to increased intracranial pressure, further compromising cerebral perfusion and potentially exacerbating neurological deficits.

what is a epidural hemorrhage ?

• bleeding between the dura & skull

what are signs of a epidural bleed ?

• short periods of LOC

• then brain herniation → coma

what is a subdural hemorrhage ?

• A subdural hemorrhage occurs when blood collects between the dura mater and the brain, often due to trauma, leading to increased intracranial pressure and potential neurological deficits.

what are symptoms of a subdural hemorrhage ?

• irritability

• vomitting

• seizures

what is a concusion ?

• A concussion is a type of traumatic brain injury caused by a blow to the head or a violent shaking of the head and body, leading to temporary disruption of brain function.

what is a mild TBI?

• a concusion

what are the clinical manifestations of a concussion? confusion and amnesia

what are Skull Fracture ?

• A skull fracture is a break in one or more of the bones of the skull, which can occur due to trauma or impact to the head, and may be associated with other injuries such as brain contusions or hemorrhages.

There are several types of skull fractures, including:

• Linear skull fracture: A crack in the skull that does not move the bone.

• Depressed skull fracture: A break that causes a portion of the skull to move inward, which can compress brain tissue.

• Basilar skull fracture: A fracture at the base of the skull that may involve the surrounding areas, potentially leading to cerebrospinal fluid leaks or cranial nerve damage.

how do you know its CSF leak ?

• positive for glucose

Submersion injury: A condition that occurs when a person is submerged in water, leading to hypoxia and potential drowning. Signs may include altered consciousness, difficulty breathing, and the presence of water in the lungs.

what is the primary cause of injury in submerssion ? hypoxia

what are indicators of a bad outcome with drowning ?

• submerssion more than 10 mins

• unresponsive to ACLs within 25 mins

what are the best predictors of a good outcome with drowing ?

• submerssion less than 5 min

• presence of sinus rhythm

• reactive pupils

• neurological responsivenss at the scene

what is meningitis ?

• Meningitis is an inflammation of the protective membranes covering the brain and spinal cord, typically caused by an infection from viruses, bacteria, or other microorganisms. Symptoms may include fever, headache, and a stiff neck, and it can lead to serious complications if not treated promptly.

  • what is nuchual ridgity ? → stiffness in the neck

What is bacterial meningitis?

• membranes that surround the brain and spinal cord

In pediatric meningitis which is more common? Viral

how would are CSF look with Bacterial meningitis ?

• Cloudy,increase WBC, Protein and glucose with a positve gram stain

what would CSF look like with Viral Meningitis ?

• clear, Slightly elvated WBC, normal protein & glucose

• - gram strain

what causes bacterial meninigitis ?

• Hib

• Streptococcus pneumonia

• Neisseria Meningitidis

what are s/s of meningitis in infants ?

• High fever

• Irritability or fussiness

• Poor feeding or refusal to eat

• Vomiting

• Lethargy or decreased activity

• Bulging fontanelle (soft spot on the head)

• Stiffness in the body and neck

• Seizures

what indicates meingococcal infection ? petechial and purpuric rashes

what are acute complications with bacterial meningitis ?

• SIADH

• Seizures

• Cerebal Edema

• Hydrocephalus

how do we check for meningitis ?

• lumbar puncture

how should we set the child up for a lumbar puncture ?

• have child empty bladder

• apply EMLA cream → 1 hr prior to procedure

• place pt in side lying cannonball position

how should the patient lay after a lumbar puncture?

• flat position for up to 12 hours → this prevents CSF leakage & headache

what vaccines prevent meningitis ? Hib & PCV

what age do we get Hib and PCV ? The Hib vaccine is typically administered at 2, 4, 6, and 12-15 months of age, while the PCV vaccine is given at 2, 4, 6, and 12-15 months as well.

what is kernigs sign ? Kernig's sign is a clinical test used to assess meningeal irritation, characterized by pain and resistance when the leg is extended at the knee while the hip is flexed at a 90-degree angle.

what is brudzinskis sign ? Brudzinski's sign is another clinical indicator of meningeal irritation, where the patient involuntarily raises their legs when the neck is flexed, indicating potential meningitis.

How long should a patient be on droplet precautions following aintibiotic treatment for menigitis ? Patients should remain on droplet precautions for at least 24 hours after the initiation of effective antibiotic therapy for meningitis

what is encephalitis ?

• Encephalitis is an inflammation of the brain, often caused by viral infections, and can lead to symptoms such as fever, headache, confusion, and seizures.

what virus normally causes encephalitis ?

• The herpes simplex virus (HSV) is one of the most common viral causes of encephalitis

what are seizures ?

• Seizures are abnormal electrical activities in the brain that can result in a variety of symptoms, including convulsions, loss of consciousness, and altered sensations.

what is the most common pediatric neurological disorder ? seizures

• most pediatric seizures are ? febrile

What are the different type of seizures and there charaterisitcs ?

• Absence Seizures: Characterized by brief lapses in consciousness, often mistaken for daydreaming; may involve subtle body movements.

  • happens between 4 & 12 years old

  • abrupt onsent → 20 or more attacks a day

• Tonic-Clonic Seizures (GRAND MAL ) : Involve a mix of stiffening (tonic) and jerking (clonic) movements and are typically associated with a loss of consciousness.

  • postical → sleepy & disorientated

• Atonic & Akinetic seizures → sudden loss of muscle tone, resulting in a fall or drop, often without warning. Akinetic seizures may involve a brief loss of awareness or responsiveness.

  • happens between 2 and 5 years old

• Myoclonic Seizure → a sudden, brief jerking or twitching of a muscle or group of muscles, typically occurring in clusters and often affecting the arms.

  • no posticial state

  • may or may non loose consiciousness

how do we identify the orgin of the seizure ?

• EEG

what seizure do we use phenytonin for ?

• Tonic clonic

• paritial

• status epileptucus

what are the phases of a seizure ?

• prodromal phase - This is the initial phase that occurs hours to days before a seizure, characterized by mood changes, anxiety, or other non-specific symptoms.

• Aura: The initial phase where the person may experience sensations that precede the seizure, such as unusual smells or feelings.

• Ictal Phase: The actual seizure event occurs, characterized by convulsions or loss of consciousness.

• Postictal Phase: The recovery period following the seizure, where the individual may feel disoriented, fatigued, or have memory loss.

what virus lies dormant? → varicella

What is strep throat? → It is an infection caused by group A Streptococcus bacteria, leading to symptoms such as a sore throat, fever, and swollen lymph nodes.

What are children with strep throat at risk for?

• Risk for rheumatic fever, which can affect the heart, joints, and nervous system.

• Potential for post-streptococcal glomerulonephritis, a kidney condition that can occur after infection.

• Scarlet Fever

What is influenza caused by? The influenza virus, which is an RNA virus belonging to the Orthomyxoviridae family, and it primarily affects the respiratory system.

What is the incubation period of influenza? The incubation period for influenza typically ranges from 1 to 4 days

What are the causes of otitis media?

• Bottle propping

• secondary smoke

• cleft palate

• URI

What viruses are communicable after symptoms subsisde ?

• epstein Barr

• HIV

How long is the treatment for strep?

• → 10 days → Penicillin

What are the symptoms for strep throat?

• headache, fever, abdominal pain & tonsils inflamed and covered with exudate

Kids with strep need to change there tooth brush after taking antibiotics for 24 hours

and cannot return to daycare until 24 hours after antibiotics.

What are the complications for flu ?

• encephalitis

• myocarditis

what is myringotomy → small incision is made in the eardrum to drain.

what is tympanostomy → placing a small tube into the incision in the ear.

What is asthma?

• Asthma is a chronic respiratory condition characterized by airway inflammation, increased mucus production, and bronchoconstriction, which leads to difficulty in breathing and wheezing.

What are the priority concerns for asthma?

• mucous production

• inflammation

• bronchial constriction

What are triggers for asthma?

• allergens

• exercising

• cold air

• tobacco smoke

Peak Flow meter → a device used to measure the maximum speed of expiration, helping to assess lung function and monitor respiratory conditions.

• perform 3x and record the highest number ( not the average )

what is cystic fibrous ?

• autosomal recessive trait that affects the lungs and digestive system, leading to the production of thick and sticky mucus that can clog airways and cause severe respiratory issues.

What gene is mutated with CF ?

• CFTR

Exocrine glands produce mucus, tears, sweat, & enzymes.

Resp. Tract & pancreas are predominantly affected.

What are the diagnostic evaluations for CF?

• sweat chloride → decreased pancreatic secretion

• increase sodium & chloride

pancreatic enzyme are required for proper digestion and nutrient absorption, and their deficiency is a hallmark of cystic fibrosis.

when do give pancreatic enzyme to patients → within 30 mins of eating

what is Sickle Cell Anemia

• Sickle Cell Anemia is a genetic blood disorder characterized by the production of abnormal hemoglobin, leading to distorted, sickle-shaped red blood cells that can cause blockages in blood vessels, resulting in pain and increased risk of infections.

When do we find out that kids have sickle cell anemia? at 6 months

• at birth, infants have 80% of HbF

dactylitis → inflammation of the fingers or toes, often occurring in infants with sickle cell anemia as a result of blood vessel blockages.

What are the types of sickle crisis?

There are several types of sickle cell crises, including:

• Vaso-occlusive crisis: This is the most common type and occurs when sickle-shaped red blood cells block blood flow in small vessels, leading to pain and potential organ damage.

• Aplastic crisis: This occurs when the body stops producing enough red blood cells, often triggered by infections such as parvovirus B19, leading to severe anemia.

• Splenic sequestration crisis: This happens when sickle cells block blood flow to the spleen, causing it to enlarge and potentially leading to a rapid drop in hemoglobin levels.

Why do they give oral penicillin prophylaxis to infants?

• Oral penicillin prophylaxis is given to children with sickle cell disease to reduce the risk of bacterial infections, particularly from encapsulated organisms like Streptococcus pneumoniae, which can lead to severe complications such as pneumonia and sepsis.

what is sickledex (dithionite)? → a blood test that assesses for abnormal hemoglobin S → it dosen’t differentiate between if the person has sickle cell trait or sickle cell disease.

What is hemoglobin electrophoresis?

• the blood test that assess for various types of hemoglobin

what medications for sickle cell anemia ?

• hydroxyurea → but it will help with SCA; it helps create fetal hemoglobin F (hgb F). this helps reduce the need for blood transfusion.

• What is a side effect of hydroxyurea? lower WBC count

• stem cell transplant → to cure bone marrow will make healthy RBCs.

what is splenic sequestration ? Splenic sequestration is a complication of sickle cell anemia where sickled red blood cells accumulate in the spleen, leading to an enlarged spleen and potentially causing a drop in hemoglobin levels.

What is the max days for IV Toradol with sickle crisis ? 5 days

What medication do we not use with sickle cell anemia?

• Meperidine (Demerol): This opioid is contraindicated because it can cause seizures and has a higher risk of adverse effects in patients with sickle cell anemia.