ET Tube size (mm) INTUBATION/EXTUBATIO Extubation Criteria

Dear Lord, You are the greatest Healer. Protect with Your mighty angels
All life and health comes from You. Those under my care. Heart Rate BP N FiO2 <50
NB 3-3.5 <1kg 2.5 mm
Without Your blessing and Your grace, When their need of me is greatest, ET SIZE P/F
There is nothing I can do. May I always be there. <2 mo 140-160 Systolic: 1-3kg 3 mm no electrolyte imbalance
Infant 3.5-4 >2y/o:
2-12 mo 120-140 upper: yrs X 2 + 90
age(yrs) + 16 control of infection
I thank you for this noble role, When my zeal is at its lowest, 1y/o 4-4.5 >3kg 3.5 mm good muscle mass
My service unto Thee. Tiredness meeting me at every turn, 1-2 yo 100-12 lower: yrs X 2 + 70
Stand by me with my patients, May you then be my Healer, 3y/o 4.5-5 4
2-8 yo 90-110 Diastolic WT v Sz
PT: 2 or 2.5
Til the work is done daily. Renewed joy and vigor earn. 6y/o 5-5.5 Racemic epi
30 mmHg lower 1-1.5 7 3 FT: 3 or 3.5
RR 10y/o 6-6.5
0.3 ml + 4.7 PNSS
Give me knowledge, wisdom and skill All this I ask from You Lord, ET Length 2.5 ml X 3d (q4-6)
To do the tasks at hand, That I may a good doctor be, <2 mo up to 60 1.5-2 8 3
Provide the best care needed That in my life as a physician,
Adolescent 7-7.5 age/2
kg
+cm12 Dexamethasone 6 hrs
For each persons best interest, stand May they see You in me. 2mo-1yr 50 Adult 7.5-8 2-3 9 3.5 prior then 24 hrs
1 7
1yr-5yr 40 2 8
Let me lend a helping hand NGT and FC size age (yrs) + 16 / 2
To those who cannot pay, 3 9
ET size age (yrs) / 4 + 4
Bringing good health to all
ET depth age (yrs) / 2 + 12 or ET size x 3
Send them fit for homewards way.
wt + 6 (neo)

Reasons for Extubation Orders IV Drips Meds Prep Dose Drug + D5W Conc
Parameters for weaning Dopamine 40mg/ml 2-20 5 + 45 4000
Extubation epinephrine neb: 0.5 + Alpha1-adrenergic effects: vascular smooth muscle contraction
Improvement in CXR 10 + 40 8000

W ork of breathing 1.5cc PNSS x 3 doses Alpha2-adrenergic effects: vascular smooth muscle contraction 5 + 495 400
ABG showing P02 >/= 50 mmHg q15 then q4 for 24 Beta1-adrenergic effects: Inotropy (contractility), Chronotropy (HR)
Blood PH >/= 7.3

E lectrolytes Dobutamine 12.5mg/ml 5-20 20 + 30 5000
hours Beta2-adrenergic effects: Vasodilation, Bronchodilation

A BG Midazolam 5mg/ml 1-10 3 + 47 300
PC02 </= 55 mmHg O2 mask at 10 5lpm Formulas Epinephrine 1mg/ml 0.1-1 5 + 15 250
Hgb 12-15g% or Hct 36-45
N utrition then titrate Conc: mL (drug) x prep (mg/mL) x 1000 Furosemide 10mg/ml 0.2-0.4 2 + 18
Weaning from CPAP
I nfection ABG 1 hour post Total Volume Nitroglycerin 1mg/ml 1-3 10 + 10 500
resolved extubation Dose: conc x rate / 60
Decrease Fi02 by 3-5% every time Pa02 > 70 DOPAMINE
N eurologic Status NPO for 4 hours weight Indications: Cardiogenic and Distributive shock
With Fi02 of 40%, reduce pressure by increments of 2
CXR 6 hours after Rate: weight x dose x 60 2-5 mcg/kg/min: improve renal perfussion
cm water every 2-4h until pressure of 2-3cm is G help me GOD! 5-10 mcg/kg/min: improve cardiac output
extubation. conc
achieved. Start dexamethasone 10-20 mcg/kg/min: post-resuscitation stabilization in patients with
Rule of 6 : wt x 6 = _ mL to make 100cc D5W (rate = dose) hypotension (conjunction with fluid therapy)
Transfer patient to oxygen hood with Fi02 of 15-50% 0.5-1mg/kg q6 prior to Onset: 1-2 min Peak: 10min Duration: <10min when infusion stopped
prep to run at _ cc / hr
extubation Do not mix with NaHCO3!

Rapid Sequence Intubation Prep: Dopamine 200/5 Computation for EPINEPHRINE

concentration: 0.02-0.08 = mostly beta1 and beta2 stimulation. C.O., mild vasodilation
NITROGLYCERIN FENTANYL
Conc Dopa D5W D5W 250 + 200 mg/amp 0.1-2.0 = mix beta1 and alpha1 , C.O., SVR = vasoconstriction Prep: 1mg/mL Prep: 50 ug/mL (1 vial = 2mL = 100ug/mL)
Atropine 0.01-0.02 mg/kg IV, min 0.1mg, max 1mg 200/250 = 0.8 mg/cc Dose: 1-3 ug/kg/min Dose: 1-3 ug/kg/hr
S 800 1 cc 49cc >2.0 = mostly alpha1, SVR and C.O. by afterload
Lidocaine 1-1.5 mg/kg IV 1 cc= 60 ugtts
Both an alpha and beta-adrenergic agent Vol of drug x prep Vol make 20cc
DS 1600 2 cc 48 cc conc= 600/60= 13.33
Midazolam 0.2 mg/kg IV ug/ugtts Actions:
Total Volume 100 mcg = wt x dose = x (cc/hr)
QS 3200 4 cc 46 cc Lidocaine 2% Low cardiac output state
2g/100ml= 20mg/ml Beta effects will improve cardiac function 20 mL x
DOBUTAMINE Alpha effects may increase afterload and decrease cardiac output
AD= rate X conc
Indications: wt X 60
Septic shock
Used in low C.O. states and CHF e.g. myocarditis, cardiomyopathy, Prep: Dobutamine 250/2 Useful for both inotropy and vasoconstriction TERBUTALINE
Rate= RD X Wt X 60 Indications: Pulseless arrest. Cold shock (hypotensive)
M.I. conc Prep: 500 mcg/mL (1mL/vial)
Conc Dobu D5W FUROSEMIDE
If BP adequate, can be combined with afterload reducer (Nipride or Dose: LD 2-10 mcg/kg, then 0.1-0.4 mcg/kg/hr, titrate in
ACE) S 1000 4 cc 46 cc Indications: Pulmonary edema. Fluid overload increments of 0.1-0.2 q 30mins
In combination with Epi/Norepi in profound shock states to DS 2000 8 cc 42 cc Onset: 5min. Peak: 30mins 1mL + 19cc D5W = 20cc
improve C.O. and provide some peripheral vasodilation
QS 4000 16 cc 34 cc Rate: mg (drug) (wt x dose x prep) Conc: 25 (500/20)
Onset: 1-2 min Peak: 10min. Duration: <10min
TV x des. Dose (dose x weight)
Do not mix with NaHCO3!

SIRS Criteria for Organ Dysfunction

AMINOPHYLLINE Presence of at least 2 of the ff 4 criteria, 1 of which must be abnormal 1.Cardiovascular Dysfunction 4. Hematologic
Prep: 25 mg/mL temperature or leukocyte count: Despite administration of isotonic intravenous fluid bolus > 40 mL/kg in 1 hr Platelet count < 80,000/mm3 or a decline of 50% in the PC from the highest
value recorded over the last 3 days (for patients with chronic hematologic or
Dose: LD 6 mg/kg over 20mins q4-6 Core temperature of >38.5 C or <36 C Decrease in BP <5th percentile for age or systolic BP < 2 SD below normal for age OR
oncologic disorders) OR
Tachcardia: > 2SD above normal for age OR bradycardia: <10th percentile for age need for vasoactive drug to maintain BP in normal range (dopamine >5 g/kg/min or
MD neo 0.2 mg/kg/hr dobutamine, epinephrine, or norepinephrine at any dose OR two of the ff: International normalized ratio >2
Mean respuratory rate >2SD above normal for age
6wk 6mo 0.5 Unexplained metabolic acidosis: base deficit >5.0 mEq/L 5. Renal
WBC elevated or depressed for age or >10% immature neutrophils
6mo 1yr 0.6-0.7 Increased arterial lactate >2 x upper limit of normal Serum creatinine > 2 x upper limit of normal for age or 2-fold increase in
INFECTION Oliguria: urine output <0.5 mL/kg/hr baseline creatinine
1 9yr 1-1.2
Suspected or proven (by positive culture, tissue stain, or polymerase Prolonged capillary refill: >5sec 6. Hepatic
9 12yr 0.9
reaction test) infection caused by any pathogen OR a clinical syndrome Core to peripheral temperature gap >3 C Total bilirubin > 4mg/dL (not applicable for newborn)
associated with a high probability of infection. 2.Respiratory Alanine transaminase level 2 x upper limit of normal for age
SEPSIS PaO2/FIO2 <300 in absence of cyanotic heart disease or pre-existing lung disease OR
NOREPINEPHRINE
PaCO2 >65 ton or 20mm Hg over baseline PaCO2 OR
Prep: 1mg/mL (1 vial = 4mL) Systemic inflammatory response syndrome in the presence of Proven need or >50% FIO2 to maintain saturation > 92% OR
Dose: 0.1 2mg/kg/min suspected or proven infection Need for non-elective invasive or non-invasive mechanical ventilation
Conc: 160 SEVERE SEPSIS 3.Neurologic
4cc + 21cc D5W to make 25cc Sepsis plus 1 of the ff: cardiovascular organ dysfunction OR acute GCS < 11 OR
respiratory distress syndrome OR 2 or more other organ dysfunctions Acute change in mental status with a decrease in GCS > 3 points from abnormal
baseline
 Heat
By Weight Na K Cl HCO3 Ca PO4 LBM PLR D5NSS
stroke
HOLIDAY SEGAR METHOD
By BSA Ludans Using D5IMB or D5NM Maintenance Fluid IMB 25 20 22 23 3 3
Vomiting D5NSS Burns PLR
1500 cc/m2/day NM 40 13 40 16 3 3
1ST 10 kg: 100 Maintenan
NSS 154 154 D5NM Azotemia D5W
ml/kg/24 hrs Newborns/cardiac: 750 WT (kgs) ml/kg/day ce
LR 130 4 109 28 3 3
Next 10 kg: 50 cc/m2/day < 0.8 80-100 D5 0.3%
NMR 40 30 BA Inc BUN D10W
ml/kg/24 hrs (Wt X 4 + 9) 100 = sq. m IsolyteM 40 35 40 NaCl
0.8-1.5 60-80
>20 kg: 20 ml/kg/24 Normogram Isolyte P 25 20 20 Fever and D5 0.3%
Bleeding D5LR
>1.5 60 PLP 48 25 20 22 sweating NaCl
hrs Mostsellers Formula:
4/2/1 Rule: (Hourly rate) Ht (cm) X Wt (kg) <3 75 0.3% 51 51 Drowning D5W UTI D5NSS
st 0.6% 102 102
4 ml/kg/hr for 1 10 3600 3-10 kg 100 D5W Profuse
0.45 77 75 Ascites D5LR
kg D10W Bleeding
10-20 kg 75 0.9% 154 154
2 ml/kg/hr for next Dengue D5 0.3%
20-30 kg 60 ORS 90 20 80 30 CHF D5NSS
10 kg Fever NaCl
P-lyte 90 90 20 80
1 ml/kg/hr for every 30-50 kg 40 P-lyte 45 45 20 35 HPN
D5W
DM PNSS
D5LR
kg >20 Reformulated 75 20 Citrate Glucose Osm 245
ORS 10 75 CHF (NPO) D5NSS

pH pCO2 HCO3 Comp

GOLDEN RULE IN ABG METABOLIC ALKALOSIS Metabolic acidosis
ANALYSIS Expected pCO2= (0.75x actual Met acid pCO2
For every 10mmHg in pCO2 HCO3)+205 PCO2= 1.5x[HCO3] +8 2
pH of 0.05 Met alka pCO2
For every 10mmHg in pCO2
Metabolic alkalosis
METABOLIC ACIDOSIS
in pH of 1 Resp acid Acid urine
Expected pCO2 =(1.5 x actual PCO2 7by mm Hg for each 10meq/L in HCO3
Expected pCO2=(Fi02)(5) HCO3) =82
Actual pCO2= exp pCO2 Resp alka Alk urine
RESPIRATORY ACIDOSIS comp met acid/alk Respiratory acidosis
Acute: pH=0.08x (actual pCO2 Actual pCO2< exp pCO2 met Acute [HCO3] by 1 for each 10mmHg in PCO2
- 40)/10 acid/alk w/ resp alk HCO3
Chronic: pH=0.03x (actual Actual pCO2> exp pCO2 met Chronic [HCO3] by 3.5for each 10mmHg in PCO2
pCO2 - 40)/10 acid/alk w/ respacid
Respiratory alkalosis pCO2 <21 21-26 >26

RESPIRATORY ALKALOSIS >45 Comp met and resp acid Resp acid Mixed met alk and resp acid
Acute [HCO3] by 2 for each 10mmHg in PCO2
Acute: pH=0.08x (40 - actual
pCO2 )/10 35-45 Met acid Normal Met alk
Chronic: pH=0.03x (40- actual Chronic [HCO3] by 4 for each 10mmHg in PCO2
pCO2 )/10 Mixed met acid and resp Combined resp and
<35 Resp alk
alkalosis metabolic alka

A B C D
Hypoxemia Oxygen Therapy(PaO2) Recurrent Pneumonia
dFiO2 Comorbid None + + +
dFiO2= pCO2/0.8 defined as 2 or more episodes in a single yr or 3 or Compliant + + - -
Normal 80-100 Uncorrected <60
713 (FiO2 decimal) - a mode episodes ever, with radiographic clearing caregivers

<80 Mild Corrected 60-100 PO2 /b between occurences Ability to ff up Possible Possible Not possible
{dFiO2x 100/c)+a} x 0.14 Dehydration None Mild Mod Severe
<60 Mod Overcorrected FiO2(mechanical ventilation)= liters/min x 4 +20
Persistent Pneumonia Ability to feed Able Able Unable Unable
>100
FiO2 PIP,PEEP FiO2 of room air=0.2 no CXR and resolution of symptoms for 1 month Age >11m >11 m <11m <11m
<40 Severe P/F= pO2/FiO2 Radiologic Lag RR
2-12 mo >50 >50 >60 >70
no radiologic change for 1 month 1-5 year >40 >40 >50 >50
Normal Values > 5 year >30 >30 >35 >35
Hypoxemia Treatment <60y/o: 400-500 infiltrates should resolved after 4 weeks
Retractions - - IC/SC Supra
PO2 <expected Uncorrected Give O2 or FiO2 >60y/o: 400(every year above 60x 5) Head bob - - + +
Cyanosis - - + +
PO2=expected Corrected Maintain 02 Grunting - - - +
P/F <expected Hypoxemic Apnea - - - +
PO2>expected Overcorrected FiO2 P/F=expected Non-hypoxemic Sensorium Awake Awake irritable lethargic
Complication - - - +
Pain Ff up after 1 week After 3 days Admit ICU

ASTHMA SCORING WOODS SCORE

Hyperreactive airways Ht in inch Exp PEFR Ht in inch Exp PEFR
0 1 2 Levels of Asthma Control

Asthma
Intermittent 109.2 43 142 139.6 55 307 Characteristics Controlled (all of Partly Controlled Uncontrolled

BPD < 4 days per week
pO2 or cyanosis 50-100 << 70 in room air <<70 in 40 fiO2
111.7 44 160 142.2 56 320 the ff) (any present in any

Cystic Fibrosis or <4 weeks Breath sounds N Unequal Absent
week)

Viral Pneumonia 114.3 45 173 144.7 57 334 Acc muscles N Mod Max
Mild Daytime sx < 2x a week >2x a week 3 or more features
Normal sleep & no 116.8 46 187 147.3 58 347 Exp wheeze N Mod Extreme of partly controlled
ASTHMA asthma present in
impairment of daily 119.4 47 200 149.6 59 360 Cerebral fxn N Depressed/coma Agitated
PEFR = [(ht in cm -100) (5)] + activities sport, leisure 1-3: mild asthma attack; 4-6: moderate, bedside; 7 up: severe, intubate any week
male/female 121.9 48 214 152.4 60 373 ASTHMA SEVERITY Limitations of None Any
Male +175 Moderate severe
124.4 49 227 154.9 61 387 Symptoms/ Day Symptoms/night
PEF or FEV 1 activities
One or more items
Female +170 127.0 50 240
PEF variability Nocturnal spont None Any
abnormal sleep 157.5 62 400
Impairment of daily Step 1 > 80 % awakening
130.0 51 254 160.0 63 413 < 1 x a week < 2x a month
% = Actual Peak Flow activities Intermitent < 20% Need for relievers None or <2x a week >2x a week
Computed Peak Flow 132.1 52 267 162.5 64 427 Step 2 Mild Persistent
1x a week but <1x a
> 2x month
>80 %
Persistent day 20-30% Lung function Normal < 80% predicted
Mild: 60-80% 134.6 53 280
> 4 days per week 165.1 65 440 Step 3 Moderate Daily attacks affect 60-80% (PEF/FEV1)
Mod : 40-60% and > 4 weeks >1x a week
137.2 54 293 Persistent ADL >30 % Exacerbations None > 1/year 1x a week
Severe : <40 %
Step 4 Severe
continuous Frequent < 60%
Persistent
 NaHCO3 Correction Nasal Prong = 25-45% = 4 LPM Total Volume (TV) FiO2 = 100% PIP = 20-30 PEEP = 3-5cm H2O
Insp. Time : >=0.5 RR = 20-30/min
500ml
dRR = RR (vent) x actual pCO2 / desired pCO2
BE>10 HCO3 <15 ph<7.3 Oxygen Mask = set at 5 LPM Volume inspired or expired with each normal breath
Insp. Reserve Volume (IRV) Initial Settings If PCO2 is high (MV is low),
NaHCO3 = wt x actual BE x correction factor Oxygen hood = set at 10 LPM 3liters Rate: 40-60 for neonates and increase rate or TV or both
*full correction = 0.6 (neonate); partial correction = 0.3 (children) Volume that can be inspired over and above the TV infants, 12-40 for grade school If using PC ventilation, increase
Oxygen tent = 50% = 15 LPM PIP
Exp. Reserve Volume (ERV) kid, 12-16 for adolescent and
**max of 50 meqs adult If PIP too high, increase the rate
MAP = PIP[IT/(IT+ET)]+PEEP [ET/(IT+ET)] 1.1 liters
instead
eg: BE=14, wt=10kg, HCO3 =8meqs Residual Volume (RV) TV: 6-8ml/kg
PIP <1kg = 14 cms 1.2 L PEEP: 3-5cm H2O If PCO2 is low (MV is high),
Order: Give 42 meqs Na HCO3 + equal amount of diluents to run Lower the rate or TV/PIP
for 1 hr then repeat ABG after 1 hr OR stat dose: 1-2 meqs/kg as Volume that remains in the lungs after maximal expiration FiO2: 100%
1-2 kg = 15-20cms
SIVP Dead space I-time: 0.3-0.5 sec for higher
>2kg = 20-25cms 150ml rates; 0.7-1 sec for lower rates
Anatomic: volume of the conducting airways PIP (for pressure control):
Nasal Cannula: FiO2 = lpm x 4 + 21 Physiological functional measurements; volume of the lungs about 18-24 cm H2O
that does not eliminate CO2 (usually greater in lung diseases Pressure support: 5-20 cm H2O
with V/Q inequalities)

Initially CPAP is set at 6cm water. If there is no inc in Acute Respiratory Distress CCAM
FiO2 = [(CAx0.2) + (PAx1)] / TFR or PEEP Tidal Volume (TV) = BW(kg) x factor Syndrome Type 1 (50%)
PO2 in 15 min, pressure must be increased in 2 cm
increments to a maximum of 10 cm. (if by ETT) or by 12 FiO2 < 60% = CA, O2; FiO2 >60% = O2, CA Normal TV: 6-10cc/k/day Factor: 5-7 cc/kg (normal lung) PaO2/FiO2 ratio < 200 mmHg Is macrocystic
bilateral infiltrates Single or several large (>2
cm (in other method). CA = (100-FiO2)/79 x TFR Child: 10-15cc/kg 10 cc/kg (abnormal lung) cm in diameter) cysts lined
acute onset
Adult: 10 cc/kg with ciliated
If there is a increase in PaO2, reduced pressure. TFR = minute volume x 2 (I:E) +2000 No evidence of left sided heart pseudostratified epithelium
failure
If 10-20 cm water pressure is attained and if PaO2 remains
= CA + PA (NV: 6-8) IE: (60/RR IT)/ IT Acute Lung Injury
Has good prognosis for
survival
under 50, FiO2 must be increased by 5-10% increments.
CPAP failure is evident if PaO2 remains less than 50 in 100% Minute Vent = RR x expected TV (age grp [10-12 PEFR PaO2/FiO2 ratio must be < 300 Type 2 (0%)
mmHg Microcystic
FiO2 with 10-12 cm water. ml/kg]) Ht=x-100x5 + 170 (F)/175(M) Multiple small cyst with
Interstitial Lung Disease
If CPAP fails under non invasive method, an ETT must be TFR = wt x 10 x 2.5 x RR / 2000 Usual Interstitial Pneumonitis
similar histology to type
% PEFR = actual/expected x 100 Associated with other
inserted. most common form in adult congenital anomalies
If CPAP fails w/ ETT, mechanical ventilation is indicated. Oxygen = TFR CA Lymphocytic Interstitial Poor prognosis
Pneumonitis Type 3
TFR = TV x BW(kg) x RR + 2000 to 3000 (dead space) most common form in children
(<10*)
Acute Interstitial Pneumonitis The lesion is solid with
rapidly progressive form of ILD bronchiole like structures
Carries the poorest
prognosis and can be fatal

(+) Mantoux Test Bronchiolitis Common Colds

PULMONARY TUBERCULOSIS > 5 mm induration PERTUSSIS
Mild URTI with sneezing Average of 6 8 colds per
s/s: 1 or more of the ff: Non BCG vaccinated child, <5 yrs (+) exposure
and clear rhinorrhea year Stage 1 Catarrhal stage (1-2 Stage II Paroxysmal Stage (2-6
Cough/wheezing > 2 weeks > 10 mm induration weeks)
accompanied by Tonsillitis weeks)
Fever >2 weeks BCG vaccinated, > 5 yrs old (+) exposure dry, intermittent,
diminished appetite and begins after 3 -1 2 days
Painless cervical and or lymphadenopathy Suggest tonsilectomy if: incubation period with irritating, hacking cough
Normal BCG Accelerated BCG fever of 38.5 39C.
Poor weight gain more than 7 episodes in the non distinctive beginning a machine gun
Does not have other
Failure to make quick return to normal health after an infection
Induration
BCG vaccination Reaction
2-3 weeks 2-3 days
systemic complaints
previous year or
more than 5 in each of the
symptoms of congestion
and rhinorrhea
burst of uninterrupted
coughs, chin and chest
Failure to respond to appropriate antibiotic therapy. Pustule formation 4-8 weeks 5-7 days held forward, tongue
CXR: hyperinflated lungs ff preceding 2 year Accompanied by low
grade fever, sneezing, protruding maximally,
Grade 0 No PTB No exposure No distress Scar formation 11-12 weeks 2-3 weeks with patchy atelectasis lacrimation and eyes bulging and watering,
Grade 1 Exposure (+) Exposure (-) mantoux WBC is usually normal conjunctival suffusion face purple
Treatment coughing ceases and a
Grade 2 Infection (+)Exposure (+) PPD (-) CXR (-) s/sx Treatment is supportive WBC 15,000-100,000
TB I: INH x 3 mos cells/mm#, loud whoop follow as
Grade 3 Disease (+)exposure (+) PPD (+)CXR & s/sx TB II: HR x 3 mos or INH x 9 mos lymphocytosis inspired air traverses the
Grade 4 Inactive + previous TB (+) PPD (-)CXR(-)s/sx still partially closed airway.
TB III: HRZ x 2 mos HR x 4 months
If > 15 years old : start quadruple therapy

TENSION MASSIVE CARDIAC

Stage III Convalescent Stage
(> 2 weeks)
Treatment
Erythromycin 40-50 mkd q 6 x
PNEUMOTHORAX PNEUMOTHORAX TAMPONADE CHF Classification
A B C
Breath sounds Ipsilaterally Ipsilaterally Normal
number : severity and 14 days
decreased decreased Anatomic: Functional Activity Well Restless, irritable Lethargic, floppy
duration of cough Clarithromycin 15 mkd q 12 x 7 I acquired I. asymptomatic
Percussion Hyperresonant Dull Normal Drink Well Eagerly Poorly
days II congenital II. Symptomatic w > ordinary
diminishes Tracheal location Contralaterally Midline or shifted Midline act Skin pinch Quickly Slowly Very slowly
Azithromycin 10 mkd OD x 5 Physiologic (disturbance
shifted
days (10 mkd on d! 5 mkd on III. Symptomatic with minimal Decide No sign Some Severe
day 2 5) Neck veins Distended Flat Distended in) activity Treat Plan A Plan B Plan C
Heart tones Normal Normal Muffled A. Heart rhythm and I V. Symptomatic at rest
conduction Fluids, Food ORS: wt (kg) x 75 100cc/kg LRS by
B.Myocradial contraction Therapeutics Follow up for 4 hours IV
C. Clinical syndrome (HPN, A. no restriction of act
DM) B. restriction of severe act
C. resctriction of moderate act
D. sharp restriction of
ordinary act
E. complete rest in a chair or
bed.
 Hypotonic Isotonic Hypertonic Malcolm Holiday (1/4 1st hr; 7 hrs)
Na (mEq/L) < 130 130-150 >150 Mild Moderate Severe
Mild Moderate Severe Hydration on Different Forms of Dehydration
<2 yo 50 100 15 Mild Moderate Severe
H2O (ml/kg) 20-100 100-120 100-120
>2 yo 30 60 90 Infant 5% 10% 15%
K (mEq/kg) 8-15 8-10 0-6 Water loss 1st hour: 1/3
Hydrite 1 tab in 100cc water = 8 hrs D5 0.3% NaCl 1st hr: D5LRS D5LRS
Chloride 10-20 8-10 0-3
Glucost 1 sachet in 100cc water = 8 hrs Child 3% 6% 9% Isotonic (50mmol/L Next 5-6 hrs: Next 5-6 hrs:
NaCL) D5 0.3% 2/3
Skin Cold/clammy Cold/dry Warm/velvety Oresol 1 sachet in 1L water = 24 hrs D5 0.3%
Lips and Parched/ Glucolyte 1 sachet in 200cc water < 2yo 50cc/kg 100cc/kg 150cc/kg D5 0.45% NaCl 1st hr: D5LRS 1st hr: D5LRS
Clammy/moist Dry Fluid
tongue extremely thirsty Hypotonic D5W, D5NM, D5 0.3NaCl, D5IMB, isolyte, volume
Hypotonic (75mmol/L Next 5-6 hrs: Next 5-6 hrs:
D5 maintresol NaCL) D5 0.45% D5 0.45%
lethargic/irritable/ >2yo 30cc/kg 60cc/kg 90cc/kg
CNS Coma/convulsions Lethargic seizures/increased Deficit,
tone
Isotonic D5LR, D5 NSS, PLR, NSS maintenance &
Temperature Decreased Normal/dec febrile
Hypertonic D50W, D10W D5 0.3NaCl in 6-
PLRS or D5LR PLRS 1/3 in 1
Hypertonic
replacement are Mix 1 part of D5 0.3% to 1 part
in 1 hr; hr; D5 combined: given plain D5W: D5 0.45%
OGT Replacement: D5 0.45% NaCl + 4 meq K or PLR to Administration 8hrs
D5 0.3 NaCl 0.3NaCl 2/3 in 48hrs as D5
BP Shock Normal/dec Normal
replace active losses in 8 hrs in 6 hrs 0.15%
Thready pulse Increased Slightly increased

IVF (1L) Na K Cl Mg Ca Base Gluc (g/L) Kcal

No signs Some signs Severe signs D5LR 130 4 109 - 3 28 50 150
Pathology: Management Induction therapy Relapse
30 ml/kg x D5 0.3NaCl 51 - 51 - - - 50 170 plasma leakage Low fat, low salt diet 60mg/BSA Prednisone in 60mg/BSA daily for 2 weeks or
<2yo 50-100ml 75 ml/kg q 4hrs divided doses for 4-6weeks, until no proteinuria x 3
1hr D5 0.45 4 Findings: Prednisone at 60mg/kg/m2 for
Infant 75 - 75 - - - 50 170 4-6weeks, if with response, then after a negative or trace consecutive days then
<4mos or 70 ml/kg x NaCl Nephrotic range proteinuria
2-10yo 100-200ml 200-400ml decrease to 40mg/kg/m2 albuminuria x 3 consecutive 40mg/BSA every other day for
<5kg 5hrs D5 0.9
154 - 154 - - - 50 170 Urine protein is 3+/ 4+ urinalysis, 4-6weeks then taper.
NaCl alternating days for 4-6weeks.
(>300mg/dl)
10 yo
As much as
5-7.5kg 400-600ml
30 ml/kg x D5NR 140 5 98 3 - 50 50 170 Spot protein/ creatinine ratio Check 3 consecutive urinalysis Maintenance therapy Steroid Resistant: persistent
tolerated 30mins PLR 130 4 110 - 3 27 - <10 >2-3:1 on ff-up taper to 40mg/BSA single AM proteinuria after 6 weeks of
Older
D5IMB 25 20 22 3 - 23 50 170 Urine albumin >40mg/m2/hr If high protein: continue dose every other day for 4 treatment
70 ml/kg x or >3.5g/24hr weeks
8-10.9kg 600-800 D5NM 40 13 40 2 - 1 50 170 If low protein: taper to 40mkd Steroid Dependent: 2
2.5 hrs Hypoalbuminemia (<2.5g/dL) for 4 weeks with alternating Taper and remove 1 tab (5mg)
*Repeat once if radial D5W - - - - - 50 170 days every 2 weeks and discontinue relapses while on alternate
11-15kg 800-1200ml Hyperlipidemia (>200mg/dL)
Wt (kg) x 75 in 4-6 hrs pulse is still very weak D10W - - - - - - 100 340 Immunizations: Flu, depending on +/- edema and day steroids or within 28 days
Edema
*if no IV, may give thru D20W - - - - - - 200 680 Pneumococcal albuminuria, total of 12 weeks of discontinuation
>16kg NGT at 20ml/kg/hr x 6hrs Labs Frequent relapse: responds
D50W - - - - - - 500 1700
(total of 120 ml/kg) Urinalysis
Pedia 30 30 20 30 4 4 L20 to treatment but had 2
TPAG relapses within 6 months
Active Fluid Replacement
Pedia 45 45 20 35 C30 D20 24 hr urine CHON after initial response or >3 in
5-10 x BM 25 cc/kg
Pedia 90 90 20 80 C30 D25 Cholesterol a year.
10-15 x BM 50 cc/kg
Reform
PPD, CXR
15-20 x BM 75cc/kg 75 20 Citrate 10 Osm 245 75
ORS

Amlodipine 2.5, 5, 10 cap 0.1-0.2 mkd OD 0.6 mkd Methylprednisolone Albumin:

Captopril 25, 50 tab 0.3- 0.5 mkd tid 6mkd (Pulse IV) Therapy
Renal Tubular Acidosis
Dose: 0.5-1g/kg/dose
Clonidine 0.1, 0.2 tab 0.05-0.3mg/ds 30ugd
Dose: 30mg/kg/dose x3 1 vial: 50cc Type I: Distal RTA Type IV: Hyperkalemic
Bid/tid
Agent Preparation Dose and Route Enalapril 5mg 0.1-0.5mkd ,od/tid 1 mkd doses monthly 25%: wt x 4 (25g/100mL) Urine pH >6 RTA
CaCO3 500mg tab 30-80 mkd TID Prep: 500mg or 1g vial 20%: wt x 5 (20g/100mL) (+) Urine Anion Gap (>0) Hyperkalemia
Felodipine 5, 10mg tab 0.18-0.56 mkd, 20mg/d
NaHCO3 8 meq (650mg) 2-3meq/Ig/d , tid/qid od/bid How to give: dilute to To run for 2 hrs x 3 doses. Hypokalemia Urine anion gap (>0)
4 meq (325mg) Give Furosemide 0.5-
Furosemide 20, 40 mg tab 0.5-2mkdose od- 6mkd make 50ml solution using Hypercalcuria Hypoaldosteronism
Calcitriol 0.25 mcg tab OD bid 1mkdose/IV mid post
D5W to run for 1 hour. Nephrocalcinosis
rHuEPO 2000, 4000u/vial 50-20u/kg SQ Hydralazine 20mg amp, 0.75 mkd qid 7.5mkd transfusion. WOF:
Each dose should be given
FeSO4 500mg/tab 1-6 mkd tid 10, 25, 50 tab congestion. Type II: Proximal RTA
at least 20 hours apart.
Hydrochlorothiazid 25, 50 tab 1mkd bid 4mkd
e WOF: HPN. Hold Urine pH <5.5
Nicardipine 2.5mg/ml 0.5ug/kg/min 3ug/kg/min Prednisone while on Negative anion gap (<0)
Nifedipine 5, 10mg cap 0.25-0.5 mkd 1mkd
Methylprednisolone
od/bid
Propranolol 5, 10mg tab 1-2 mkd bid-qid 4-6mkd
Spirinolactone 25mg tab 1mkd bid-tid 3mkd

Henoch Schonlein Purpura Systemic Lupus Erythematosus

Renal Tubular Acidosis Anion Gap
Vasculitis of small vessels Laboratory Findings: Discoid rash Renal disorder: persistent
Diagnostics: Management: Blood: Most common non- CBC Oral ulcers or nasopharyngeal
proteinuria >0.5 g/day or >3 plus
or cellular casts
Urinalysis Bicarbonate replacement Na- (HCO3 + Cl) thrombocytopenic purpura ESR ulceration, usually painless
(+) ANA
Photosensitive rash
Serum and Urine Proximal RTA: NV: 12+/-4 mEq/L in children Urinalysis Serositis: pleuritis or pericarditis
Arthritis non erosive arthritis >
electrolytes check anion 20mEq/kg/24hr NaHCO3 Renal biopsy mesangial Hematologic disorder
Urine Often follows an URTI 2 peripheral joints
Coombs (+) Hemolytic anemia
gap deposits of IgA Malar rash
Distal RTA: 2-4 (Urine Na + Urine K) urine Cl Hallmarks of the disease with reticulocytosis or
Metabolic derangements Leukopenia: <4,000/mm3 total
Urine anion gap = UNa+ mEq/kg/24hr NaHCO3 Normal: Acetazolmide, RTA, AGE, pancreatic fistula Palpable purpura lastf froim Immunologic disorder on two or more occasions or
UK- Ucl Potassium correction 3-10 days Treatment: Anti DNA antibody Lymphopenia: <100,000/mm3
Low: NS, lithium ingestion, MM Arthritis localized to knees Adequate hydration Anti Sm
BUN, creatinine, calcium, KCl in 4-6mEq/kg/day in Antiphospholipid antibodies
phosphorus divided doses
High: Methanol, Uremia, DKA, Paraldehyde ingestion, and anles woth edema Bland diet
Anticardiolipin Ab
Bood pH 10% oral KCl (1.34 mEq/ml
INH toxicity, Lactic acidosis, ethanol overdose, salicylate Abdominal pain Pain control False positive RPR or VDRL x 6
poisoning intermittent Oral or IV corticosteroid 1-2 months
UTZ KUB solution) (+) lupus anticoagulant
Renal involvement 20-25%, mkd
Durule (10mEq/durule) hematuria, proteinuria, or Neurologic disorder: seizures or
Skeletal survey psychosis in the absence of
both offending drug
Bone aging
 HSP Nephritis SLE Nephritis GFR >90 normal BUN Conversion Factor : 0.357 (mg/dl mmol/l)
Class I: no histologic
Creatinine Clearance = Ht(cm) x factor(K) = mg/m/ 50-90 mild renal insufficiency Creatinine Conversion Factor : 88.4 (mg/dl mmol/l)
Small vessel vasculitis
characterized by a abnormalities are detected Based on height Adult min 10-50 moderate
purpuric rash, arthritis, Class II: mesangial Lupus serum Crea (mg/dl) <10 severe (ESRD) Kidney Size :
nephritis
(x)(htcm) 140-age x wt L = 0.379 x age (yr) + 6.65
abdominal pain and
glomerulonephritis IIa: mild mesangial serum creamg/dL (x)(creamg/dL) K values : N Serum Crea = 0.6 mg/dl + 2
hypercellularity 24 hour Creatinine Clearance :
Symptoms: x Values x Values LBW 0.33 (up to 12 y/o)
Cr Cl : (U x V)/P x 1.73 /BSA
IIb: moderate mesangial FT (0-18 months) 0.45
Appear 1-3 weeks after an preterm, lbw, <1y/o: 0.33 Male: 72 ml/min/1.73m
hypercellularity and Children 2-12 0.55 Estimated Crea Clearance
upper respiratory tract increased matrix term, infant, < 1y/o: 0.45 Female: 85 U : urine crea (mg/dl)
Ado girls 13-21 0.55
infection = Ht (cm) x BUN/ 0.357 V : total urine volume (ml)
Class IV: diffuse proliferative children, adolescent Ado boys 13-21 0.70
Renal manifestations Crea/88.4 Duration of collection, 1440 min
Nephritis, the most common female: 0.55
occur up to 12 wk after and most severe form P : plasma crea (mg/dl)
adolescent male: 0.7
the initial presentation of Class V: membranous Lupus
HSP Ucrea x vol
Nephritis, the least common.
Pcrea x 60 x 24x 1.73/BSA

Total Protein Spillage Hyponatremia Hypernatremia

Values:
mild 125-135 nausea, malaise Correction time: TNaR X 24
80-120 normal mod 110-120 lethargy, headache Na infused D5W or NSS
Total urine CHON gram x 1000 = mg/hr/m severe <110 coma, seizure Correct in 24-72 hrs, rpt after 12 hrs Should not be >0.5 mEq/kg/hr or 10-12 mEq/kg/d
24x BSA
50-80 renal impairment
20-50 renal insufficiency D5 0.3 in 1L= 51 meqs If symptomatic: 1. NBW= wt X 0.6
Normal : 100 m/m/24or < 4 mg/m/hr D5 0.45 = 77 meqs Use 3% NaCl (Na 513 meqs) 2. CBW= NBW X (desired/actual)
5-20 renal failure D5 0.9 = 154 meqs Dose: 4-6cc/kg/dose to run for 1 hr
Nephrotic range : > 40 mg/m/hr 3. EFWD= NBW-CBW
Abnormal range : 4-40 mg/m/hr <5 uremia Prep: 2.5 meq NaCl + 4 cc dist H2O
4. EFWD + Maint FR (HS)= TFW
Total sodium requirement: deficit + Repeat serum Na after 4 hrs
GFR= 125ml/min (75-150) maintenance S/E: bleeding
Deficit: (desired actual) X wt X 0.6 145-157 correct in 24 hrs
24hr urinary crea Maintenance: 2-3 meqs/kg (meq X ORAL MEDS: 158-170 48 hrs
wt) NaCl tab = 17 meqs/tab
Male = 15-20 ug/k 171-183 72 hrs
1 mg NaCl= 0.43-0.48 meqs,
Female = 10-15 ug/k Total sodium = Na content X TFR (rate X 24) incorporate in feeding 184-196 84 hrs
Infused in 24h 1000 ml

Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia Hypomagnesemia

0.2-0.3 PL max4-6meqs Oral Meds: KCl syrup: 5 Antagonize K effect of Preparation: 100mg/mL eg. Wt=5kg rate= 42cc/hr
meqs/5 hrs Classic ECG changes Acute: Volume expansion, MgSO4: 25-
0.5 CL irritability: Correction= 200-500mg/k/d or Incorporate 10 cc of 10% Ca diuresis(not
Prep: 2meqs/ml 6-7meq/L:peak T waves 2-4cc/kg/day gluconate in 326cc IVF every 8 50mg/k/g/dose IV
Meqs x IVF rate with shortened QT Ca gluconate 0.2-0.5cc/kg/IV x 5 thiazides),steroids,calcitonin.
wt Kalium durule 10meqs/durule mins Maintenance: 1-2cc/kg 10% Ca hrs for 3 doses.rpt Ca after phosphates, dialysis wt x dose
7-8 meq/L:widened of QRS gluconate 3rd dose OR
100 Fast correction:<2 Shift K intracellularly Chronic: restrict Ca Incorporate _mg
>8 meq/L: sine wave Vtach, NaHCO3 at 1-2 meqs/kg/IV x 30 Calcium gluconate IV (acute) Wt x dose/ 100 cc=_cc intake,steroids,phosphate
0.5-1 meqs/kg =D5W to make Vfib and asystole MgSO4/rate q6 x 2 hrs
20cc to run for 1-2hrs as side mins PO (chronic) Divide it to frequency (q6-8)
Ex. K=2.5 wt=15 IVF=55cc/hr Glucose +insulin drip:5cc/kg OR + equal amount of
drip to D5LR (max 10 meqs), (max 10cc) diluted in equal Add equal amount diluents or
Increase 6meqs KCL/100cc IVF D10 + 0.1 unit/kg actrapid over volume distilled after x 3 make 20cc IVF to run for 1 hr x
to run at same rate to be After 1h,maintain KIR to 0.2- diluent x 2hrs x 4 doses
30-60 mins doses q8 hours 3 doses q8
given for 3 doses 8 hours 0.25, rpt K after 4 hrs q6
B2 agonist at 1-5 mcg/kg/min IV Do not mix with lactated
interval or neb at 10-30 mg over 15 Monitor DTR, UO
CC=wt x 2(max 100cc or 1 g) in Ringers
For repeat serum K 8 hour mins
post correction Kayexelate: 1-2 /kg PO q6 8 hrs
Emergency dialysis Diluent IVF: (rate x 8) 10cc

DIABETES MELLITUS Target Blood Sugar

Human Insulin Pre Meals : 80-120 mg/dl
Confirmatory Tests Management:
Insulin diet for virgin cases
Split- mixed
Premixed
2 hr post prandial : 100-140 mg/dl DIABETIC KETOACIDOSIS
FBS > 126 mg/dl, divide by 18 Before exercise > 100
C-peptide if already on insulin LA + RA insulin IM q6
for mmol/l After exercise < 250
5 Cornerstone of treatment : DIEDS
Total Caloric Intake based on HS :
Heavy glucosuria > 55 mmol/L
RBS> 200 mg/dl Diabetic education,
Insulin therapy
Onset Peak Duration
1000 + 100 x yrs old Ketonemia with or without ketonuria
Heavy glucosuria (>
55mmol/l) Type 1 : Insulin def RA 15-30 mins 1-3hr 3-5hr Divide into 50% CHO, 10-15% CHON, 30-35% fats Hyperglycemia > 200mg%
Type 2 : Metformin only med for
Possible ketonuria (>4 kids SA 30m-1h 2-4hr 5-8hr Distribute into 3 meals and 3 snacks Metabolic Acidosis :
mmol/l) Exercise IA 2-4hr 4-12hr 12-24hr 20 % BF, 20% lunch, 30%dinner, 10% each snack
Diet 30 mins after IM, eat meals
pH < 7.3
LA 2-4hr None 24hr
Impaired Glucose Tolerance Sugar monitoring HCO3 < 15mmol/L
Split mixed insulin
FBS 110-125 mg/dl (6.1 7 Laboratories : If premixed : Total insulin requrement : Signs and symptoms of dehydration vomiting,
mmol/l) VBG 30 kg, 10 yrs old 30 units 20u pre BF (70) <2 yrs old : 0.5 u/kg/d drowsy, hyperventilation
2 hr glucose 140-200 mg/dl Serum RBS, Na (hypo), K (hyper), 10 u pre dinner (30)
BUN, Creatinine >2 yrs old : 1 u/kg/d
Urinalysis with ketone bodies If split mixed 30 units 20 u 14 u, N, 6u R Teens : 0.6-1.5 u/kg/d
CBC 10 u 7u,N, 3u R Compute for TIR
Insulin Syringe : 30 u = 3/10 cc 1 u/line = 30 cc
Insulin determination AM 70% 70% IA, 30% SA
HbA1C 50 u = cc
PM 30% 70% IA, 30%SA
Long lead II check T waves (peaked) 100 u = 1 cc 2u/line
 TIME THERAPY COMMENTS Insulin Therapy Potassium: 20-40 meqs KCL/L
Classification of DKA Quick volume expansion; may be >2yrs: 0.1 u/kg/hr If sugar is 300mg%, shift to D5 0.45 NaCl
repeated. NPO. Monitor I/O, <2yrs: 0.05 u/kg/hr
10-20ml/kg IV bolus 0.9% NaCl If RBS decreases by > = 100mg%/hr, titrate drip by 25% but dose
1ST HOUR neurologic status. Use flow sheet.
or LR 5 u insulin in 50cc PNSS or 10 u in 100 cc PNSS
Normal Mild Moderate Severe Have mannitol at bedside; 1g/kg IV should be < 0.05 u/kg/hr
push for cerebral edema Insulin should not be started until shock has successfully
CO2 (mEq/L,
20-28 16-20 10-15 <10 If > 100, increase drip by 25%
venous) Insulin drip at 0.05 to reversed and a saline/K rehydration given.
0.10u/kg/hr If HypoNa, Correct Na: Corr Na = actual Na + (act RBS
pH (venous) 7.35- 7.45 7.25- 7.35 7.15- 7.25 <7.15
IV rate:
This avoids sudden influx (20meq KCL/L) 100/100 x 1.6)
Kussmaul or 2nd HOUR until
DKA resolution
0.45% NaCl plus cont insulin drip 85cc/kg + MTN bolus Insulin drip: 1:1 1U SA + 1ml PNSS Check Serum Osmolality
Kussmaul depressed 23 hours
Oriented, alert
respirations; respirations; 5:50 5u SA + 50 cc PNSS HCO3 not to be used in initial resuscitation, if needed, 1-2
Clinical No change oriented but sleepy to 20 meq/L
but fatigued
sleepy; depressed; KPhos and 20meq/L KAc 10:100  10u SA + 100 cc PNSS meqs/kg over an hour
arousable sensorium to 5% glucose if blood sugar
<250mg/dL (14mmol/L)
Transition to SQ
coma
If K < 3 meqs/L, give 0.5 to 1 meq/kg
Wt x dose x diluent Clinical improvement, no acidosis, tolerated oral intake. To
as oral K solution OR increase IV K to Amount of insulin (wtxdose) prevent rebound hyperglycemia, do not stop IV insulin infusion til
80meq/L 60mins after 1st SQ injection of regular insulin
Oral intake with subcutaneous No emesis; CO2 > = 16 meq/L;
Variable
insulin normal electrolytes Prefers 10u SA + 10cc PNSS

OSMOLALITY AGE Hgb Hct

Management: HEMATOLOGY COMPUTATIONS ACTUAL RETIC. COUNT (ARC) ABSOLUTE NEUTROPHIL COUNT
Serum Osm 48-69,48- Actual Hct x reticulocyte ct Wbc x N + B
Monitor q1 VS, CBG, I & O, sensorium 1-3 days 14.5-22.5
= 2(Na) + Glu (mg/dL) + BUN (mg/dl) 75,44-72 MCV = (hct x 100)/RBC count Clinical SIADH CSW CENTRAL Desired Hct
Monitor q4-6 hrs electrolytes NV: 80-100 RETICULOCYTE INDEX
18 2.8 Parameter DI 5000 Normal
Check ABG 2 mos 9-14 28-42 MCH = (hgb x 100)/RBC count = ARC/2
NV 275-295 mOsm/L NV: 28-32 Serum Na Low Low High 1000 1500 Little/dec. risk for
O2 6-12 mos 11.5-15.5 35-45 = Hct / retic ct x 2 infection
MCHC = (hgb x 100)/hct
Fluid Management: Urine Osm = (USG-1000) x 40,000 NV: 32-38%
Urine Output Normal High High > 2 = hemolysis 500-1000 Moderate
M 13-16 37-49 or Low
PNSS bolus 10-20cc/kg over 10-30mins, repeat if poor pulses NV 400-600 mOsm/L 12-18 mos Mentzer Indez: MCV/RBC < 2 = BM suppression < 500 Severe
F 12-16 35-46
Check TFR = deficit + maintenance NV: <13: thalassemia Urine Na High Very Low
Dianostic Criteria of SIADH M 13.5-17.5 41-53 >13: IDA High DOUBLE VOLUME EXCHANGE
Def = est% dehydration (cc/kg) x BW (kg) 18-49 HYPERLEUKOCYTOSIS
Absence of: renal, adrenal, or thyroid F 12-16 36-46 TRANSFUSION
Calculate MTN using HS Reticulocyte Index Intravascular Normal Low Low Total WBC > 100,000 cu mm
insufficiency, CHF, nephrotic syndrome, or AGE WBC COUNT Volume status or High = KBW x Estimated body vol. x 2 3L per BSA D5 0.3NaCl per day (<5y
Add deficit to 48hrs MTN, give it evenly over 48hrs as PNSS Actual x RC
cirrhosis, diuretic ingestion, dehydration 2L; >5y 3L)
Birth 9-30 desired 10 Serum Uric acid Low Normal High
initially (2x MTN + def/48hr) Urine Osmolality > 100 (usually>plasma) 1-1.5 Normal PARTIAL EXCHANGE TRANSFUSION Allopurinol 100mg/m2/dose q8
Serum Osmolalty < 280 and serum 24 hrs 9.4-34 or High (>6y 1tab; <6y tab)
Fluid input of >4L/m2 per 24 hrs has been suggested as risk <1BM failure = KBW x Est vol x Hct Actual Desired
factor in cerebral edema sodium < 135 1 mo 5-19.5 >1 erythropoeisis Vaopressin Level High Low Low NaHCO3: 2-3 mEqs/kg/day or
actual Hct incorporate 50 mEqs
Urine Na >25 1-3 yrs 6-17.5 1 u = inc. Hgb by 2; Hct by 3 NaHCO3/500cc IVF
Corrected Reticulocyte Count:
4-7 5.5-15.5 Actual <2.5 penia Monitor USG <1.010, UO
Desired x hct (age) >2.5 cytosis >100cc/m2/h, pH 7-7.5
8-13 4.5-13.5
adult 4.5-11

Whole 20cc/kg 1 u increases hct PHLEBOTOMY if hct >65%

ALL HIGH RISK PROTOCOL TBV (Total Blood Volume) FWB blood by 1.5%
Phases: Full term 56 male, 60 female
80-90cc/kg 20cc/k (max) FFP 10-15cc/kg IDA: Response to Iron Therapy
Induction weight(kg) x80cc x 15%; or Hypochromic/Microcytic Anemia:
Preterm 90-100cc/kg Vol = desired actual Hgb x 6 x wt pRBC 10-15cc/kg 1 u increases hct
Consolidation (Bld vol)(wt) (D A) Replacement of intracellular
Child/Adult male 70ml/kg = desired actual Hct x Wt by 3% 2 mL = 1 g
Actual Hct 12 24h iron enzyme, decrease RDW MCV RC
Maintenance hgb
female 65ml/kg Rate = vol x 12 gtts/ml = gtts/min Maximum Blood extraction in irritability, increase appetite
Vincristine 15mg/m2 on D0,7,14,21 Cryoprecipi 1 u/ 6kg 1 u increases IDA Inc Dec Dec
60 min x 4h Newborn Initial bone marrow response,
Doxorubicin 25mg/m2 on D0, tate factor VIII act by 24 36h
2% as fast drip 80mL x kg x 10% erythroid hyperlasia ACD Inc Normal Normal
7,14,21 pRBC
Prednisone 40mg/m2 on D21-25 Plt conc 1 u/10kg or 1 u increases APC May use PNSS or FFP Reticulocytosis, peak at 5 7 Thal Normal Dec Inc
10-15cc/kg, 5cc/k in neonates 7lbs 0.1 0.2 by 10,000-15,000
48 72h
L aspariginase 6mg/m2 for 9 doses days ARD Normal Normal Dec
Vol = desired actual Hgb x 2 x wt u/kg
or 3 doses per week; mwf/mtw 1 4h Increase Hgb levels
= desired actual Hct x Wt Aplastic Normal Inc
Formula:
4 30min Repletion of stores
Sedimented RBC Desired hct Actual hct x weight
Folic,
15cc/kg (kg) Inc Inc
B12
cc/kg/aliq must not exceed actual
Plt conc: FeSO4
hgb levels
1 u/6 KBW Order Therapeutic Dose: 4-6 mkday q8
1U = 30-50ml (raises plt by 10T) Prepare and transfuse properly
for 1-3 months
typed and crossmatched 1 u Prep: 30mg/5ml, 15mg/ml
FFP pRBC divided into 3 aliqs, each aliq
Fld rate (5-20 cc/k/h in 4h) x 2 hrs., 6 hrs apart

Thalassemia Aplastic Anemia 0-5 mins DIAZEPAM >30 but <60 mins PHENYTOIN If with significant THIOPENTAL DRIP CSF Pathway:
Anemia Pallor Dose: 0.3 mg/kg or 0.5 mg/kg Dose: 20 mg.kg IV hyponatremia Dose: 5mg/kg/bolus Choroid plexus Lateral ventricleForamen of Monroe
per rectum Rate: 1 mg/kg/min Give 3% NaCl at 4 cc/kg IV to Drip: 1-5 mg/kg.hr
Hepatosplenomegaly Petechiae 3rd ventricleAqueduct of Sylvius 4th ventricle
Rate: 1 mg/min Max: 100 mg run for 1 hr Prep: 1 g/50 mL vial
Skin Bruising Increased susceptibility to Foramen of Lushka and Magendie Subarachnoid space
Max: 5 mg for infants, 10 mg in Onset: 10-30 mins, Duration: 48- Prep: 1 cc of 2.5 meqs/cc NaCl + PROPOFOL DRIP
Failure to thrive infection older children/adults 4cc SW Subarachnoid villiVenous system
96 hours Dose: 2 mg/kg IV bolus (1
Slight to jaundice Easy fatigability Onset: 2-3mins, Duration of LUMBAR PUNCTURE:
>60 mins REFRACTORY MIDAZOLAM DRIP mL/kg)
Abnormal facies malar Labs action: 16-90mins, may repeat
after 15 mins STATUS EPILEPTICUS Dose: 0.4-0.5 mg/kg bolus Drip: 2-10 mg/kg/hr Done bet. L2-L3 at level of ASIS
prominence, frontal bossing, Anemia
For myoclonic and Absence Drip: 1-18 mcg/kg/min, can Prep: 10 mg/mL/50 mL vial Normal Opening Pressure: 80-150 mm H2O
depression of nasal bridge, Leucopenia 5-20 mins PHENOBARBITAL increase to 23 mcg/kg/min
exposure of upper central teeth Thrombocytopenia Dose: 20 mg/kg IV or IM Status Epiplepticus: VALPROIC Normal Closing Pressure: 10-20 mm H2O
Prep: 3 mg/kg in 50cc D5W
Treatment: Treatment: Rate: 1-2 mg/kg/min ACID where 1 mcg/kg/min=1 Random Blood Sugar: 3.9-6.7 mgs%
Transfuse when hgb falls Max: 800 mg 20-40 mg/kg IV, infuse at 0.5-1 ugtt/min may increase by 1 ugtt
Prednisone 1 mg/kg/day
mg/kg/hr to be given in 30 mins q 10-15 mins as needed
Order:
<7g/dl Blood transfusion Onset: 20-30 mins after the loading dose Send the ff. for analysis:
If ferritin is > 1000ng/ml, Duration: 24-72 hours
give40-60 mkd SQ over 8-10hr Exclusion: <1 yo, plt ct <150,000, Tube 1= cell ct., diff ct.
x 5 days/week, monitor levels 20-30 mins deranged LFTs 2= sugar, CHON
q3-6 months additional 10 mg/kg if max dose 3= GSCS
splenectomy had not been reached yet, NPO for 4 hrs, resume feeding once fully awake, flat on bed for 4 hrs
otherwise proceed to Phenytoin
Monitor VS q15 for 1 hr, q30 for next 2 hrs, q1 until stable
 Traumatic/Bloody Tap: TERM PRETERM
OLDER
PMN Mono Wbc Bacterial Meningitis
CHILDREN
For every 1,000 RBC= 1 WBC Partially Tx
110-140 PT 0-100 0-25 0-100 Bacterial TB/ Fungal Viral Common organisms
For every 800 RBC= increase of 1 mg% protein Quantity 40 mL 10-30 mL Bacterial
mL NB 0-170 0-20 0-500 0-1 Month: GBS, E. Coli, L. Monocytogenes, Gram Neg
For every 1 WBC= 600-1,000 RBC
CSF/Blood Ratio= 0.6 Color
Xanthoch Clear-
Clear Early Color Purulent Turbid Colorless Colorless 1-3 month: Above + H. Influenzae, S. Pneumoniae
romic xantho 0-25 0-5 0-30
Neonate 3month- 6 years: H. Influenzae, S. Pneumoniae, N. Meningitides
Lumbar Tap 0-100 None
RBC 0-100 Late Appearance Milk like Sl turbid Ground glass Clear Treatment:
Pressure (in cm H2O) 0-5 0-5 0-10
Neonate
G 22 (1 )= gtts in 21 sec 0-15 0-10 N. Menigitides PCN 5-7 days
G 22 (3 )= gtts in 39 sec WBC 0-32 Sugar <50% >50% <40% 40-60
thereafter 0 0-5 0-50 H. Influenzae: Ampicillin/ Chloro 7- 10 days
G 20 (3 )= gtts in 12 sec
79-80% 70-80% 50% S. Pneumoniae: PCN 10- 14 days
WBC correction in traumatic tap Glucose CHON 100-200 Dec >100mg% 50-100
E. Coli: Ceftriaxone 14-21 days
Peripheral WBC x 1000 = WBC Protein 60-150 60-200 10-20
5,000,000 1000 RBC RBC Almost neg 0 0 0
C/I
CSF Protein CSF Sugar= CSF Sugar CSF Cell count:
Increase ICP WBC >1000 100s 20-500 0-20
NB 45-100 mg/dL RBS or Hgt 500 RBC= 1WBC
Severe CP depression
Child 10-20 mg/dL cut off: >50-60% 500-700 RBC = 1g/%CHON Inc lympho (inc
Infected skin Almost 100%
Ado 15-30 mg/dL If Hgt: divide by 18 Diff. count L>P PMN in 1st 48 lympho
Decreased platelet ct. or Blood D.O PMN
hrs
Brain Abscess

TB Meningitis Cushings Triad Medical Measures Cerebral Edema

Hypertension Temperature Control
Brain Herniation: Transtentorial Stages
Stage 1: Irritability Outcome
Fully recovers or with mild physical
Bradycardia Head Position 15- 30 degrees to
nonspecific s/sx: Fever, maximize perfusion Type Location Site BBB Mechanism Parameter DIENCEPHALIC MIDBRAIN- MEDULLARY
headache, irritability abnormality not interfering with Tachypnea/ Irregular
lifestyle respirations Seizure control and prophylaxis Inc. Vascular PONTINE
no focal neurologic signs Vasogenic Extra cell WM Disrupted
Mild sequelae such ad mild mental Normal ICP Fluid management permeability Resp pattern Regular or Regular or Slow, irregular,
stagnation or loss of abnormality or degree of
developmental milestones Infants: 10- 100mmHg (15) Sedation Cytotoxic Intra cell W/GM Intact Cellular failure cheyne-stokes increased gasping resp
hemiparesis, deafness or epilepsy
Adult: 80- 180 CSF removal Ischemic Both W/GM Disrupted Anoxia Pupil size Small reactive Midposition, fixed Midposition,
Stage 2: Pressure or Convulsive Severe sequelae such as
hydrocephalus or hemiplegia Grossly Obese: 250 Osmotic agents: dilated, fixed
Lethargy, nuchal rigidity,
Died during in patient treatment 20% Manitol 0.5g/kg (2.5cc/kg) Hydrostatic Extra cell W/GM Disrupted Increase BP
seizures Cerebral Perfusion Pressure= withold if sOSM 320mOSM/kg Ocular movement Reflex ocular Reflex. Reflex absent
(+) Kernig, Brudzinkis sign, Treatment
MAP- ICP Furosemide: 1mg/kg/dose Plasma hypo- movts present Dysconjugate/
hypertonia,vomiting Anti TB Drugs: HRZ x 2mo + Osmotic Both W/GM Intact absent
STP/ETH daily then 10mo HR+/- Goal: MAP for Age - 15 Acetazolamide osmolality
(+) FND: Inc ICP, HCP, ETH/STP daily or 3x/wk Motor response Hypertonicity, Hypertonic Flaccidity
Hyperventilation, decrease
Encephalitis 20% Maniitol (0.5- 1g/kg or 5cc/kg pCO2 to 30-35mmHg  decorticate decerebrate
Stage 3:Paralytic or Terminal q6 with BP prec) vasoconstriction  decrease
Coma, Hemi/ paraplegia, HTN Dexamethasone (1mkd q6 x 4 cerebral blood flow
weeks then taper) Steroids
Decerebrate posturing,
deterioration of VS VP shunting if with HCP

Guillan-Barre Syndrome Fever of Unknown Origin Critical Phase KAWASAKI DISEASE

Motor Neuron Defects fever documented by a health When the temperature
Paralysis Diagnostics care provider and for which the drops to 37.5- 38C or less
gradual onset preceded by viral CSF ANALYSIS- 2x elevated cause could not be identified
and remains below this level, Types: Presence of at least 4
usually on days 3-7 of illness,
Upper Motor Lower Motor infection (10d) GI or respiratory CHON, no pleocytosis <10 wbc after 3 wk of evaluation as an an increase in capillary Classic fever >5 days + principal features:
starting from lower ext then trunk, (albumino cytologic outpatient or after 1 wk of
upper extremity and bulbar permeability in parallel with 4/5 criteria Changes in extremities
Atrophy - + dissociation), normal glucose evaluation in the hospital increasing hematocrit levels
muscles Acute erythema of palms,
Babinski/Clonus + - NCV- reduced; EMG- Acute may occur Incomplete or Atypical soles, edema of hands, feet
Bulbar involvement muscle denervation The period of clinically
DHF Phases persistent fever but fewer Subacute periungal pealing
Tone Spastic Flaccid Respiratory insufficiency/ significant plasma leakage
dysphagia Febrile Phase usually lasts 24-48 hours than 4/5 of fingers, toes in weeks 2 and
DTR Hyperreflexia Hypo/areflexia Management Progressive leukopenia 3
EOM involvment rare- Miller
Observe for resp muscle paralysis
Fever of 2-7 days and is often
accompanied by facial flushing, followed by a rapid decrease Clinical criteria: Polymorphic exanthem
Fasciculations - + Fisher Syndrome (External in platelet count usually
Ophthalmoplegia, ataxia, Plasmapheresis
skin erythema,generalized body
precedes plasma leakage
Fever persisting at least Bilateral bulbar conjunctival
areflexia) ache, myalgia, arthralgia and
headache Recovery Phase five days remittent injection without exudates
IVIG
Urinary incontinence or retention Gradual reabsorption of Changes in lips and oral cavity:
Tendon reflexes lost extravascular compartment erythema, lips cracking,
fluid takes place in the strawberry tongue, diffuse
Autonomic NS- postural following 48-72 hours
hypotension injection of oral and pharyngeal
mucosae
Cervical lymphadenopathy

Phases: Diagnostics ACUTE STAGE Immunizations of MMR and varicella should be

Acute Febrile Phase CBC normal to elevated with Intravenous immunoglobulin 2 g/kg delayed for 11 months
1-2 weeks high neutrophils
CRP persist for 4-6 weeks
over 10-12 hr
If refractory, may add another infusion of IVIG at
LEPTOSPIROSIS
fever and the other acute signs Anti-inflammatory aspirin 80-100 mkd
ESR persist for 4-6 weeks q6 hr until 14th day of illness 2 g/kg. If not responded, give IV
Myocarditis
Platelet count normal in 1st wk, CONVALESCENT STAGE methylprednisolone at 30 mkd for 3 days PHASES ANICTERIC ICTERIC (WEILS DISEASE)
Subacute Phase
increases by Antithrombotic aspirin 3-5 mg/kg OD IVIG dose: 2 g/kg
Fever and other acute signs have abated 3-7 days
2D echo should be performed orally until 6-8 wks after onset 3-7 days
Irritability, anorexia, and conjunctival injection may persist
at diagnosis prep: 2.5g/50

Starting on the 14th illness day OR Fever, myalgia, Fever, jaundice,
Desquamation, thrombocytosis, development Ifof aneurysms
normal, then a repeat study afebrile for at least 2-4 days headache, abdominal
Septicemic phase hemorrhage, renal
Highest risk of sudden death should be performed during pain, vomiting,
the illness then 6-12 months TD 1: wt x 0.5 or (0.01 x 60) for 30 mins. failure, myocarditis, (+)
lasts until about the 4th wk conjunctival suffusion
after onset LONG-TERM THERAPY FOR THOSE blood, CSF
Convalescent Phase TD 2: wt x 1 or (0.02 x 60) for 30 mins.
If (+) aneurysm, give WHITH CORONARY 10-30 days
All clinical signs of illness have disappeared until the ESR and CRP return to
normal for the first 6 months, after 6 ABNORMALITIES TD 3: wt x 1.5 or (0.03 x 60) for 30 mins. 4-30 days Fever, jaundice,
months, give dipyridamole. Aspirin 3-5 mg/kg OD orally + Immune (Leptospiruric)
6-8 wk after the onset Meningitis, uveitis, rash, hemorrhage, renal
If > 2.5mm, discontinue ASA clopidogrel 1 mg/kg/day (max: TD 4: wt x 2 or (0.04 x 60) for 30 mins. phase
75mg/day) fever, (+) urine failure, myocarditis
* remaining to be given in 10 hours (+) urine
ACUTE CORONARY THROMBOSIS
Prompt fibrinolytic therapy with
tissue plasminogen activator,
streptokinase, or urokinase under
supervision of a cardiologist
 Treatment: Meningococcemia Malaria Hemolytic Uremic Syndrome
Penicillin G IV (6-8 million U/m2/day divided every 4hr IV for 7 days) Diagnostics: thick and thin blood S: Chloroquine phosphate 10 mg
Tetracycline (10-20 mg/kg/day divided every 6 hr PO or IV for 7 days Initially may mimic viral Treatment smear base/kg PO immediately followed Triad Manifestations:
as alternative) illness with pharyngitis, P. falciparum 9-14 days by 5 mg base/kg PO at 6, 24 and
Penicillin G (250,000-400,000 Microangiopathic hemolytic Preceded by AGE 3 weeks prior:
fever, myalgias, weakness, U/kg/day q4-6 hr IV) DOC P. vivax 12-17 days 48 hr, total dose 25 mg base/kg
Oral Amoxicillin 30-50 mkd q8 (max 2g/day) is an alternative anemia diarrhea that is initially but then
vomiting, diarrhea and/or Cefotaxime (200 mg/kg/day) P. ovale 16-18 days, as long as 6- R: Quinine sulphate: 8.3 mg
therapy for children <9 years of age becomes bloody
headache or ceftriaxone 12 months base/kg (10 mg salt/kg) PO tid x Thrombocytopenia
Chemoprophylaxis: Doxycycline (200 mg PO once a week) (100mg/kg/day) for 5-7 days P. malariae 18-40 days 3-7 days May present after an URTI
Maculopapular rash (7% of Uremia or renal injury
Prodrome: lasting 2-3 days before Doxycycline : 4 mkd PO bid x 7 d Sudden onset of pallor,
cases), limb pain, myalgias or Tetracycline 25 mkd PO qid x irritability, weakness, lethargy,
parasites are detected in the
or refusal to walk in many 7d or Clindamycin: 20 mg/kg/day
cases
blood Thrombotic and oliguria usually occurs 5-10
Symptoms: headache, fatigue, tid x 7 days days after the initial
Fulminant Thrombocytopenic Purpura
anorexia, myalgia, slight fever, gastrointestinal or respiratory
meningococcemia and pain in the chest, abdomen Triad + CNS involvement +
illness
progresses rapidly over hours and joints relapsing fever
to septic shock Classic presentation: Paroxysmal
PE
prominent petechiae and of fever alternating with periods dehydration, edema, petechiae,
purpura (purpura fulminans), of fatigue but otherwise relative hepatospenomegaly, and
hypotension, DIC, acidosis,
adrenal hemorrhage, renal weakness marked irritability
failure, myocardial failure and
coma

lesions occurs giving

appearance spreads

Mild and consists of

erythema in the 2nd
rapidly to the trunk

clearing of macular
Juvenile Rheumatoid Arthritis

INFECTIOSUM (5TH

symptoms of mild
low grade fever,

Low grade fever

diffuse macular

the rash a lacy,

STAGING OF TETANUS

Slapped cheek

extremities as

headache and
stage. Central
and proximal
Vital Signs

TTP, aseptic
appearance
4-28d (16d)
ERYTHEMA

reticulated
Parvovirus

meningitis
DISEASE)

5-15 yrs
STAGE I MILD II MODERATE III SEVERE
Age at onset: <16 yr

none

none
URTI
Incubation period 14d 10-14d <10d Age BP CR RR
Arthritis (swelling or effusion, or the presence of > 2 of the ff signs:

redness and occipital

spreads to the neck,

Asymptomatic, mild

junction (Nagayama
occurs at the uvulo-
Rose colored, small
Limitation of range of motion Duration >6d 3-6d <3d Premature 55-75/35-45 120-170 40-70

lymphadenopathy
URTI, conjunctival
face and proximal
trunk and usually
discrete papules
Tenderness or pain on motion Moderate, risus

6-15th month

palatoglossal
(EXANTHEM
0-3 mos 65-85/45-55 100-150 35-55

5-15d (10d)

extremities
Trismus Mild Severe

SUBITUM)
ROSEOLA
sardonicus

3-5 days
Increased heat in > 1 joint

HHV-6
3-6 mos 70-90/50-65 90-120 30-45

None
spots

none

none
rare
Dysphagia Absent Present Severe
Duration of disease: > 6 wk 6-12 mos 80-100/55-65 80-120 25-40
Pronounced, gen Severe, causing

and extremities (rash

temp, dec on d3-4 as

Onset type defined by type of articular involvement in the 1st 6 months

spreads centrifugally

begins; suboccipital,

are most prominent

RUBELLA (GERMAN
Rigidity Localized

to involve the torso

anterior cervical LN
Begins on the face

appearance of the

Congenital rubella
lymphadenopathy
and neck as small,

malaise, anorexia,

postauricular, and

5 days before to 6

pregnant exposed
esp <14 wks AOG
with episthotonus fracture

Sudden onset inc

1-3 yrs 90-105/55-70 70-110 20-30

Low grade fever,

eyes, headache,
sore throat, red
after

coalesce, and it

ISG 20-30cc to
days following
rashes appear
irregular pink
6-18th month

macules that
Mild, transient More sever, longer, Violent, frequent,
Spasms 3-6 yrs 95-110/60-75 65-110 20-25
MEASLES)
Polyarthritis : > 5 inflamed joints

minimal
<10sec 10-30secs >30secs

14-21 d

3 days)
Toga
Oligoarthritis: > 4 inflamed joints

rash
and
Symp NS absent absent Present 6-12 yrs 100-120/60-75 60-95 14-22
Systemic disease: arthritis with a characteristic intermittent fever >12 yrs 110-135/65-85 55-85 12-18
RUBEOLA (MEASLES)

IVIG 0.25 ml/kg up to

prior to onset of rash
photophobia, coryza,
cough and increasing

Inc temp abruptly as

line, behind the ears
Rash begins around

rash up to 4-6 days

fever, Koplik spots
conjunctivitis with
the forehead (hair

3 days before the

Exclusion of other forms of juvenile arthritis

and on the upper

Treatment:

appears 1-4 days

BPN, OM, SSPE

desquamation
after its onset
macupapular
neck as a red

rash appears

d5 exposure
Diazepam PRN: 0.05-0.15 mg/kg/dose

Mild fever,
Paramyxo

1C Temp = RR by 4

eruption
All ages Midazolam drip: 0.01-0.06 mg/kg/hr

Branny
8-12d

Antibiotics: Metronidazole 30mkd q6 max 4g/d

x 10-14d CR by 40
Incubation period

Pen G 100,000 u/kg/d q4-6 max 12mud

Rash and Spread

Infective period

Desquamation
Epidemiology

Complication
Tetanus Ig: 3,000-6,000 u/IM SD

Prophylaxis
Prodrome
Etiology

IVIG: 200-400mg/kg if TIG n/a

Fever
Weight Length/Height BMI Weight Status Head Circumference

BP (for ages 1-10 yrs) At birth 3 kg or 6.5 lbs At birth 50 cm or 20 in <18.5 Underweight At birth 35cm Growth Assessment
0-3 mos + 9 cm 18.5 24.9 Normal weight 1st 4 mos in/mo = 2 in Average Weight Gain: 10-20g/kg/d
SBP = 2 x yrs +70 (p5) 0-6 mos mos x600 + BW (g)
25 29.9 Overweight 5-12 mos in/mo =2 in < 2kg: >15g/kg/d
2 x yrs +90 (p95) 6-12 mos mos x 500 + BW (g) 3-6 mos + 8 cm
30 34.9 Obese 2nd yr 1 in/yr > 2kg: >20g/kg/d
6-9 mos + 5 cm
DBP = 2/3 SBP 3-12 mos mos + 9 / 2 35 39.9 Moderately obese 3-5 yrs in/yr =1.5 in Preterm: (age in days 7-10) x 15-20 + BW (g)
9-12 mos + 3 cm
1-6 yrs yrs x 2 +8 40 49.9 Morbid obesity 6-20 yrs in/ 5 yr =0.5 in Term: (age in days 10-14) x 15-20 + BW (g)
1-6 yrs yrs x 5 + 80 = cm
Pre HPN 7-12 yrs (yrs x 7 5) / 2
yrs x 2 +32 = in Average Length Gain: 0.7-1cm/wk
Term (Age in days 10) x 20 + BW in Body Surface Area
Average SBP or DBP that p90 but 95th 4-6 mos 2x BW gm Term: 0.69-0.75cm/wk
4 yrs 2x BL 0-5 = wt x 0.05 + 0.05
10 = it takes 10 days to regain Preterm: 0.8-1cm/wk
HPN 1 yr 3x BW 2-12 yrs yrs x 6 +77 = cm its BW 6-10 = wt x 0.04 +0.1
20 = 20 gm/day Average Head Circumference: 0.5-1cm/wk
Average SBP or DBP 95th on 3 occasions 2 yr 4x BW 6-12 yrs yrs x 2.5 + 30 (in) Preterm (Age in days 14) x 15 + BW in 11-20 = wt x 0.03 +0.2
>1.25cm/wk is abnormal (HCP, IVH)
Ave wt gain *500 = 15g/day in / 5 yrs = 1.5 in gm 21-40 = wt x 0.02 +0.4
14 = it takes 14 days to regain
*600 = 20g/day 13 yrs 3x BL its BW Shortcut = (wt x 4 +9) / 100

Average Physiologic Capacity of the APGAR

Stomach
Physiologic Changes
Neonatal Care: Breastmilk Storgae Period
Days old ml/kg BW 0 1 2
Room temp (<25C) 24 hrs Physio jaundice: 2-7 days Hypoproteinemia
1 2 Breastfeeding Activity (muscle No activity Some flexion Very active
Room temp (>25C) 4-6 hrs Physio anemia: Passage of meconium: 1st
2 4 4 mos: q3h 1st wk to 6-8 wks (FT) 12 hr of life tone)
Refrigerator (4C) 8 days Pulse (HR) none <100 bpm >100 bpm
3 10 > 4 mos: q4h 4-6 wks (PT) Genital crisis: 1st wk of life
4 16 Freezer of 1 door ref 2 wks Physio weight loss Desquamation: 1st wk of Grimace No response grimace Good cry
Milk formula: 4 oz
5 19 Freezer of 2 door ref 3 mos 5-10% in 1st 14 days (FT) life Appearance blue Pink, bluish Pink all over
4 mos: q3h 14-21 days (PT) Witchs milk: resolves in (color) extremities
6 19 Deep freezer (-20C) 6 mos
> 4 mos: q4h Dehydration fever: day 2- 1-2 wks Respiration none Slow, irregular Regular
7 20 3
8 23 All premature MF: 24 cal
Falling off of umbilical 2-3 severely depressed
9 26 Sucking reflex: 34 wks cord: 10-14 days (FT)
10 27 Lanugo hair 4-6 moderately depressed
Casein MF: Al 110
Age in mos 2 - oz 7-10 vigorous
>6mos 8 oz
 Criteria for Referral for Audiologic Evaluation
BRONCHOPULMONARY DYSPLASIA
Age Guidelines for Children and Speech Delay
Criteria for discharge: Newborn Screening: (months)
Gestational Age <32 weeks >32 weeks
Weight 1.4kg Done after the 48th hr until the 72nd hr of life 12 (-) differentiated babbling or vocal imitation
18 (-) use of single word Time point of assessment 36 wks PMA or discharge 28 days but <35 days
Steady weight gain Using the heel prick method 24 Single-word vocabulary of </= 10 words
home, whichever comes first;
treatment with >21% oxygen
postnatal age or discharge
home, whichever comes first;
for at least 28days treatment with >21% oxygen
Able to feed Disorders included: 30 Fewer than 100 words; evidence of 2-word comb
for at least 28days
36 Fewer than 200 words; no use of telegraphic sentences
No hypothermia Congenital hypothyroidism 48 Fewer than 600 words; no use of simple sentences clarity of MILD Breathing room air at 36 wks Breathing room air by 56 days
PMA or discharge home, postnatal age or discharge
No hypoglycemia Congenital adrenal hyperplasia </= 80%
whichever comes first home, whichever comes first
Diagnostics:
Galactosemia
With competent caretaker 1. EOAE MODERATE Need for <30% oxygen at Need for <30% oxygen at 56
Phenylketonuria Healthy ears will echo the click sound back to a microphone inside 36wks PMA or discharge days postnatal age or
Good urine output Those who fail EOAE undergo BAER for a more definitive evaluation home, whichever comes first discharge home, whichever
Glucose 6-Phosphate Dehydrogenase Deficiency 2. BAER comes first
Identify further degree and type of hearing loss
SEVERE Need for >30% oxygen and/or Need for >30% oxygen and/or
Till age 4 positive pressure at 36wks positive pressure at 56 days
3. Play Audiometry: 5-7 yrs old PMA or discharge home, postnatal age or discharge
4. Pure tone audiometry: >7 yrs old whichever comes first home, whichever comes first

Treatment ROP Concentric Zones Centered on Optic Disc Perinatal Asphyxia

Supplemental O2 >90% GUIDELINES Rofound metabolic acidemia (ph <7.0) in cord sample
Fluid restriction 12ml/kg/day Infants <1500 at birth
Gestational Age <32wks AOG Zone I Posterior or inner zone Extends twice the disc APGAR 0-3 for >5mins
Furosemide 1-2mg/kg q12 PO or IV macular distance, or Clinical neurologic sequelae seizures, hypotonia
>1500g but with unstable clinical course
Inhaled beta agonist: Ipratropium Bromide 175mcg diluted INITIAL EXAM 30in all directions
in 3cc NSS q8 Evidence of multiorgan dysfunction
4-6 weeks of chronological age
Corticosteroids 31-33wks postconceptional age Zone II Middle zone Extends from the outer
Age Weight ET size Depth
Dexamethasone 0.25mg/kg bid for 3 days, then tapered by 10% edge of zone I to the
dose decrease q3 days for a total of 42 days ora serrata nasally and
ROP most often diagnosed at 32-44wks after conception to the anatomic
<28wks <1000 2.5 6.5-7
Hydrocortisone 5mg/kg/day q6 for 1 week, taper for 2-5 weeks
Follow up usually 2 weeks or less equator temporally
Prednisone 2mg/kg/day PO bid x 5 days, then 1mg/kg/dose PO OD 28-34wks 1000-2000 3.0 7-8
x 3 days then 1mg/kg/dose every other day for 3 doses Every wk for high risk Zone III Outer zone The residual crescent
Nutrition: 120-150 kcal.kg/day Every 2-3wks for stage 1 or 2 in Zone II that extends from the 34-38wks 2000-3000 3-3.5 8-9
Every 4-6wks for stage 1 or 2 in Zone III outer border of zone II
At 6-12 months of age to assess sequelae to the ora serrata >38wks >3000 3.5-4.0 >9
temporally

Depth: size +6

4
- PHYSIOLOGIC PATHOLOGIC
1
Dopamine/Dobutamine 4 2nd-4th day (term)
Respiratory Distress syndrome 0 1 2 3 ONSET At birth <24
4th-7th day (preterm)
Amount = (wt x dose x 6)/preparation rate: 0.5cc/hr TV 50cc d Age of onset 1-4 5-8 9-12 >12
PEAK 20 days 20h
Severity Reticulogram Cardiothymic Air bronchogram a Interval b/w No spontaneous
Amount = (wt x dose x 6)/preparation/2 rate: 1cc/hr TV 25cc Pattern Shadow y <24 24-48 >48 12mg/dl (term) >12mg/dl (term)
s
symptoms spasm LEVEL (TB)
Mild mild, hazy, Clear, defined Perihilar, within Duration of Transient on 14mg/dl (preterm) >14mg/dl (PT)
persistent >2 <2
Order: amount + __cc of diluent to make50cc of solution generalized shadow a spasms stimulation FRACTION Inc. B1 B2>B1
f Temperature
mod generalized Discernible Just past CT t >3C 2-3C 1-2C Normal- 1C B2 (DIRECT) 1.5-2mg/dl >2mg/dl
borders Variation
e
Pneumonia definite definite Suspect Nil RATE OF INCREASE Not >mg/dl/24h >5mg/dl
Initial Vent Settings in neonate Moderate Heavier, confluent Hazy Past 2/3 of lung r
Atelectasis widespread limited Mild Gradually dec by 5th day,
b DURATION disappear ny 7th day (term), Persists beyond 2 weeks
Settings Low Moderate High Severe White out lungs Up to lung periphery Cardiac borders not i NEONATAL SEPSIS
r LATE, LATE or 14th day (PT)
visible CHARACTERISTICS EARLY ONSET LATE ONSET
PIP <18 18-24 >24 t (NOSOCOMIAL ONSET) H.influenza, E.coli,
ETIOLOGY S. pneu, S. aureus, Pseudo
h Birth to 7 days, usually Klebsiella
PEEP <4 5-6 >7 Treatment: Age at onset
<72hrs
7-30 days >30 days
MORTALITY 20% 10-50%
(
Betamethasone 12mg q24 x 2 doses OR Dexamethasone 4mg IV q6h r Maternal complications Common Uncommon varies
I Time 0.4 0.4-0.8 >0.8 No steroids if >34wks AOG e
BREASTFEEDING JAUNDICE BREASTMILK JAUNDICE
a Prematurity Frequent Varies Usual Rises 4th DOL, may reach 20-30mg/dl on D14 then
Rate <20 20-40 >40 Surfactant 4-6cc/kg within 1st 8-12HOL, given on 4 quadrants, s Maternal genital Environment/communit
3RD-4TH DOL (1st WOL); 12mg/dl
dec slowly N by 4-12 weeks
hyperventilate, do not suction then CXR after 6hrs s Organism source Maternal genital tract Due to B-glucoronidase w/c inc enterohepatic circ,
Flow <8 8-10 >10 e
tract/environment y Dec milk intakeenterohepatic circ
normal LFT, no hemolysis
s Manifestation Multisystem Multisystem or focal Multisystem or focal
MAP <8 8-12 >12 s
Normal, NSY, NICU,
If BF stopped, rapidly dec bilirubin level in 48th
Site NICU, community NICU, community Fluid and caloric supplementation more frequently hour if resumed may inc to 2-4mg/dl but not to
s Community previous level
c

ZONE JAUNDICED AREAS EST. BILIRUBIN (mg/dl) usually begins on the face- 5mg/dl; midabdomen- 15mg/dl; feet- PRETERM:
20mg/dl
I Head, neck 6-8 EXCHANGE
B1 hyperbilirubinemia is bright yellow or orange CATEGORY PHOTOTHERAPY
II Upper trunk 9-12 TRANSFUSION
B2 is greenish or muddy yellow
III Lower trunk, thigh 12-16 <1250 5-7 10-13
Manifestation of color starting at serum bilirubin levels 5-7mg%
IV Arms, legs, elbow, knees 15-18 1250-1499 7-10 13-16
V Hands, feet >15 1500-1999 10-12 16-18
CRITERIA TO RULE OUT PHYSIOLOGIC JAUNDICE:
Clinical Jaundice in the 1st 24h of life 2000-2495 12-14 18-20
Inc in TB at >5mg/dl/day (85umol/L)
TB >12mg/dl in FT and >15mg/dl in PT HEALTHY TERM:
B2 >1.5-2mg/dl (26-34umol/l)
<24H
Jaundice lasting for more than 1wk for term, 2 weeks for PT
24-48H >15 >20
49-72H >18 >25
>72H >20 >25

SICK TERM:
<24 10-14 20
>24 15 20
 Phototherapy: Ex: PT, Wt 1.36kg INTRAVENTRICULAR HEMORRHAGE Cranial Ultrasound
A TSB f 20mg/dl at 48 hr of life may be treated initially with wt x 100 = 1.36 x 100 = 136 x 2 = 275ml
phototherapy Early < 72 hours < 1.2 kg
36 x 10% = 13ml (5-10% bid vol) Initial
If the TSB decreases by 1-2mg/dl within 4-6hr of starting
phototherapy, exchange transfusion may not be necessary ml for exchange should be <13ml Late >72 hours Premature <34 weeks PT < 27 wks AOG
may give 50-70% of 13ml per exchange < 1000g: within 1st 3-5
Distance from the light to the infant: 12-16 centimeters (460- Grading
490nm) exchanges = 275ml/10 = 27.5 exchanges
In germinal matrix only days of age, 75% will be Asphyxia with CNS
Surface area: Larger skin area that is exposed, the more Order detectable
effective Without ventricular
1-1.5kg = at 7-14 days
PT 36 weeks with trauma
Prepare & transfuse type O FWB < 3 days old 275cc for DVET, get dilatation
DVET electrolytes, bili, PT, PTT prior to DVET
With ventricular dilatation CT SCAN done at 4-7 Full/bulging fontanel
Removes 50% bilirubin, 98% previous blood circulating after DVET: get Hgt, ABG, elec, CBC, PT, PTT 6 hrs post get bilirubin 6, 12 DOL
antibodies (30-45%) incidence of Seizure
hrs after DVET
PT 90-100cc/kg Term: 80cc/kg
motor/intellectual Ff-up study
Risk: acidosis, hypocalcemia, hypokalemia, impairment done at 36-40 wks post PT with apnea (1-2 days)
Blood: FWB <3days old coz K+ increases rapidly
With parenchymal menstrual age or prior to
Modified WB: no platelet extension (60-80%) discharge
Use 10cc syringe for >1kg, 5cc for <1kg incidence of
motor/intellectual
impairment

SODIUM
Neonatal Seizures POTASSIUM
HYPERKALEMIA: >6
PT 2-3 meq/kg/d Term: 2-5 meqs/kg/d PT 0-1 meq/kg/d Term: 1-2meqs/kg/d Maintain normal pH: if acidotic, consider NaHCO3 (1 meq/kg) and/or
Preparation: 2.5 meqs/mL
Check glucose, if (+) give If sz > 60 mins  refractory Preparation: 2 meqs/mL Maximize acetate in hyperalimentation (acidosis drives K out of the cell).
2cc/kg D10W status epilepticus K infusion rate: not =/> 0.3 meq/kg/hr for more than 3 hours Give Ca gluconate 50mg/kg to neutralize cardiac effects (arrythmia) of
HYPONATREMIA <135
Pb 20mg/kg IV at rate of 1-2 Start Midazolam drip Hyperkalemia
mg/kg/min Deficit = (Desired Na Actual Na) x 0.6 x wt Consider glucose 0.5-1.0 and insulin 0.1u/k infusion for 30 minutes
LD: 0.15 mg/kg HYPOKALEMIA
MD: 0.1-0.4 mg/kg/hr 2.5 mEq/mL
If uncontrolled, Pb 10mg/kg Deficit = (Desired K Actual K) x wt x 0.01 x 50
IV, max of 40 Prep: 3 mg/kg in 50cc D5W = (135 mEq 128 mEq) 0.6 x 1.5 kg CALCIUM
where: 1mcg/kg/min = 1 2.5 mEq/mL 2 mEq/mL Maintainance: 100meqs/kg/d
If still uncontrolled, give ugtt/min, may increase 1 ugtt
Phenytoin 20mg/kg IV rate = 6.3/2.5mL = 2.3mL Maintainance = 2mEqs/kg/d Preparation: 100mg/mL
q 10-15 mins PRN
of 1 mg/kg/min 2mEq/mL
Or Lidocaine drip 10% Ca gluconate (9.4 mg/mL elemental Ca)
If uncontrolled, give Maintainance at 3 mEq/k/day = 6.3/2.5mL = 2.3mL
LD 4 mg/kg/hr (1st day) or 2 = 0.8 kg x 100mg/kg = _80mg___
Lorazepam (0.05-0.1 mg/kg mg/kg NaCl = 1.5 x 3mEq/k = 4.5 mEq
100mg/mL 100mg/mL
IV) or Diazepam (0.3 mg/kg Reduce by 1 mg/kg/hr on 2.5 mEq/mL 2.5 mEq/mL KIR: meqs x rate/wt CT: TKR x 100/meq = 0.8 mL to be incorporated in 24 hr fluid
max 5mg) subsequent days = 1.8mL
WOF hypotension 100 rate
Total NaCl = 10.8 mEq (4.3mL) to be incorporated in 24 hr fluid with repeat
serum Na 12 hours later

INTRALIPID
HYPOCALCEMIA (<2.2 mmol/L)

20/oz
1.1 ccal/cc (10%)
10% = 10 g/100mL

20cal/67 cal/dL

CHO

72.7

66.4

13.3
For ionized Ca <0.1, supplement with 10% gluconate (100mg/kg q6h x 4 doses)
0.2 cal/cc (5%)

7.8

7.5
7.4

8.6
8.9
Then recheck after 4th dose 20% = 20g/100mL (180cal/100mL)

10% = 1.1 kcal/cc

With seizure, give 10% Ca gluconate 2mL/kg/dose over 10mins then maintain at
0.67 cal/cc (7%, 5%)

41.96

38.93
Eg: wt 2k at intra dose = 0.5 gkD (10%)
30cal/oz
24cal/cc
20cal/cc

FAT
MJ &Nestle = 1:1
75 mg/kg/day based on the elemental Ca (400-500/k/day of 10% Ca gluconate divided into ABG in NEO

20% = kcal/cc

3.6

4.5

3.6

3.9
3.5

4.2
4.1
31
82
40 cal 2kg x 0.5 x 100 = 10 mL (of 10%1L)
40cal/100cc/10g

4 doses)
20cal/100cc/5kg

4 cal/sachet
pH 7.3 7.5
20cal/100cc/5g

1cc = 4 cal

2.25/dL
10
200cal/cc/5 g

pCO2 35 45
20cal/100cc

Administer 200mg/kg slow push 120 cal

VAMIN/AMINOSTERIL
20 cal

100cc pO2 60 80

3.42g/dL
Ca = 1.5kg x 200mg/kg = __300mg___

CHON g
0.4cal/k
0.2cal/k

HCO3 19 32
7%

125mL
1.1d/L

2.5/dL
2.8/dL

1.5/dL

2.4/dL
100mg/mL 100mg/mL CHON: 2.5 4 kd Amino 6%

24/oz
14.09
9.09
1 oz. evaporated milk

2.3
2.4
O2 90 95%

2.5

1.1

1.2
= 3.0 mL diluted 1:1 slow IV push

3
Glucose: 5.9 MK
1 oz powdered milk

Correction at 400mg/kg//day

67.6/dL

21.4/oz
AMINOPLASMIN

100/dL
813/dL
120/oz
75/dL
Prep per Liter: CHON 60g

72/dL

67/dL

80/dL
81/dL
699/L

671/L
22/oz

21/oz
22/oz

20/oz
22/oz

20/oz
Ca= 1.5kg x 400mg/kg = __600mg___ Vitamin K

CAL

100
100mg/mL 100mg/mL Calories: 650 cal <1 kg: 0.5mg
Ordinary MF

5 gms sugar
INTRALIPID
D5 0.3 NaCl

Abott, wyeth = 1:2

AMINOSYN
1 tsp. sugar

ALBUMER
Karo syrup
1 oz sugar

= 6.0 mL divided into 4 doses then diluted 1:1 for SIVP with cardiac Glucose: 100g
Pediasure

>1 kg: 1mg

PRENAN

monitoring
D5 IMB

VAMIN

Start dose at CHON = 0.5 gKD eg: wt: 1kg

D10W
D50W
D5W

Nutren jr
HMF

Neosure
Caro syr
D10

Corn oil
1kg x 0.5 x 1000 = 8.3cc Vamin/12h

Lactum

S26lbw
Enfalac

Prenan
bm(pt)
HYPERCALCEMIA: >2.6 mmol/l

Promil
Bonna
D5

bm (t)
Alfare

Nan 1
MILK

MLIK

Gain

S26
Hydrate the patient at wice the maintenance then give Furosimide 1mg/kg/dose 60

Fluconazole Erythromycin Stage 1 Stage 2 Stage 3

Stage
Infection: 12 mg/kg LD then 6mg/kg/dose IV or PO GERD: 10 mg/kg/dose PO q6 x 2 days HEMORRHAGIC DISEASE OF THE NEWBORN (mild) (mod) (severe)
Prophylaxis: 3 mkdose 2x/week then 4mg/kg/dose q6 x 5 days Hyperalert
Level of consciousness Lethargic or obtunded Stuporous, comatose
Infection: 10mg/kg/dose PO q6 Irritable
Thrush: 6 mg/kg on D1 , 3mg/kg/dose q24 PO Types Onset Factors Manifestations
Pertussis: 12.5 mg/kg/dose PO q6 x 14 days Flaccid, decerebrate
NM control Normal Mild hypotonia
Erythropoeitin: FeSO4: Maternal intake a.Muscle tone Mild distal flexion Strong distal flexion
Intermittent
Early onset 0-24 h of anticoag or Serious bleeding Dec/absent
200 400 u/kg/dose 3-5x/week for 2-6 weeks 2mg/kg/dose, max 15mg/d b.Reflexes Overactive Overreactive
Absent
anticonvulsant c.Myoclonus Present/absent Present
Total dose per week is 600 -1400 u/kg SQ Begin treatment after 2 weeks decerebrate
d.posture flexion Flexion
Lanzoprazole If <1kg, 4mg/kg/d Cutaneous/GI
Classic 2-7d No vit K at birth Suppressed
Prep: 15mg/0.6mL, 75mg/0.6mL bleeding Reflexes Normal Absent
0.73 1.66 ,g/kg/dose PO OD a.Suck Weak
Weak/absent
Absent
Amphoterecin B Exclusively Weak, incomplete
Aminophylline b.Moro Strong
Overreactive
Absent
D1: wt x 0.5 + 6cc D5W as TD to run for 6 hrs OD Late onset 2w-6m breastfed c.Tonic neck normal Absent
LD 8mg/kg/IV or PO D2-14: wt x 1 + 6cc D5W OD to run for 6 hrs infants
AUTONOMIC Parasympathetic
MD 1.5 3mg/kg/dose PO or IV q8-12 after LD DART Trial (Dexamethasone) Sympathetic Both systems
FUNCTION Miosis
0.075 mkdose q12 x 3d Mydriasis Poor light reflex
Shift to Theophylline (15mg/0.3mL) A.Pupils
Spontaneous
Spontaneous, occ
Periodic, apnea
0.05 mkdose q12 x 3d B.Respiration apnea
Vitamin E: 5-25 u PO C.Heart rate
Tachycardia
Bradycardia
Variable
0.025 mkdose q12 x 2d Sparse Variable
Vitamin A D.Secretions
Normal/dec
Profuse, increased
variable
0.01 mkdose q12 x 2d E.GI motility diarrhea
5000 IU/IM 3x/week for 4 weeks
 Common, focal or Uncommon (excl
Seizures none
multifocal (6-24 hr) decerebration)
Early: generalized Low
voltage slowing Early: periodic pattern
Late: periodic pattern, with isopotential
EEG findings normal
seizures focal or phases
multifocal, 1-1.5 Hz Late: isopotential
spike and wave
Duration of symptoms <24 hrs 1-14 days Days to weeks