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J. Mirzo. Central Washington University.

Hydrocephalus in Children Description: It is a condition that results when normal exit and absorption of cerebral spinal fuid in the ventricles are impaired cheap provigil 200 mg mastercard. Tis leads to progressive accumulation of this fuid in the ventricles of the brain cheap 100mg provigil otc, resulting in progressive damage to the developing brain with associated mental retardation and visual impairment. Causes - Congenital abnormality - Intraventricular hemorrhage - Infection - Head trauma - Brain tumor Signs and symptoms - Accelerated head growth - Te baby’s sof spot (anterior fontanelle) is usually full or bulging, or even tense, due to the increased pressure inside the head. Myelomeningocele Defnition: Congenital defect in vertebral arches with cystic dilatation of meninges and structural or functional abnormality of spinal cord or cauda equina. It is broadly classifed into 2 entities: - Open head trauma in which there is a scalp laceration with underlying skull fracture and breached Dura Mater (i. It can also be classifed by severity into mild, moderate and sever head trauma depending on the level of consciousness. Patients with severe maxillofacial injury will also need to be given a tracheostomy. Mannitol should be used with caution in patients with clotting disorders because it afects coagulation, and in congestive heart failure patients it increases intravascular volume before it causes diuresis. Remember steroids (dexamethasone, hydrocortisone) have no place in management of acute head injury. Complications - Post-traumatic seizures - Permanent neurological disability - Post-traumatic hydrocephalus - Post-Concussion Syndrome - Infection e. It is subdivided into acute (< 72hours) Subacute (between 72 hours and 3 weeks) and Chronic ( > 3weeks). Chronic Subdural Hematoma Cause - Minor head injury or fall ofen not remembered by patients or relatives. Epidural Hematoma Defnition: It is the collection of blood between the skull and the Dura Mater caused by a rupture of artery and vein in epidural space, as a result of a fracture of the skull at the moment of the impact in 60-90% of cases. Intracranial Hematoma Defnition: Traumatic intraparancymal hemorrhage is commonly associated with brain contusion. Simple Rib Fracture Defnition: Simple rib fracture is a break in continuity of the rib(s). Flail Chest Defnition: Segmental fracture of rib(s) resulting in paradoxical movement of the chest that may lead to respiratory dysfunction. Pneumothorax Defnition: Collection of air in pleural cavity which can be either simple or under tension resulting in pressure on the mediastinum. Cardiac Tamponade Defnition: Te collection of blood in pericardium causing cardiac dysfunction. Ruptured Diaphragm Defnition: A tear in the diaphragm which allows protrusion of abdominal organs in the chest. Pulmonary Fibrosis and Bronchectasis Defnition: Fibrosis of the lung following bacterial infection and/or lung abscess. Lung Cancer Defnition: Malignant growth of the bronchials or parenchyma of the lung. Mediastinum Masses Defnition: Space occupying lesions that may be solid or cystic located in the mediastinum compartment. Note: For more information refer to relevant textbooks (Short Practice of Surgery by Bailey and Love and Principles of Surgery by Schwartz) 3. Congenital Diaphragmatic Hernias Defnition: Is the herniation of abdominal viscera into the chest cavity through a congenital defect of the diaphragm. Abdominal Injuries Defnition: It is an injury to the abdomen, it may be blunt or penetrating and it may involve damage of abdominal organs. Colon Injury - Immediate surgery - Primary closure and proximal defunctioning colostomy/ ileostomy - Peritoneal lavage - Excision and exteriorization of two ends with re-anastomosis at 3months 4. Rectal Injury - Most ofen penetrating - Can occur with pelvic function Diagnosis - Blood on examination glove - Sigmoidoscopy Management - Primary repair - +/- colostomy - +/- pre-sacral drainage 128 Surgery Clinical Treatment Guidelines 5. Oesophagial Atresia Defnition: Congenital disorder with a blind end to the oesophagus, at frst feed the infant coughs and may become cyanosed. Cause - Congenital Signs and symptoms - Drooling, poor feeding, cyanosis, coughing, gagging, and chocking with attempted feeding tube is not able to pass all the way to stomach. Diagnosis - Clinical Investigations - X-ray with contrasts of oesophagus shows an air flled pouch and air in the stomach and intestines - Inserted feeding tube appear coiled up in the upper oesophagus - Oesophagocopy 5 - Chest x-ray Complications - Aspiration pneumonia - Chocking and possible death - Feeding problems - Refux afer surgery - Stricture of the oesophagus Management - Oesophagial atresia is considered a surgical emergency - Feeding gastrostomy Surgery Clinical Treatment Guidelines 129 Chapiter 5: Disorders of Gastro-Intestinal System - Control of electrolytes imbalance replace accordingly with corrective measures of dehydration - Ensure nutritional support - Good oxygen circulation - Put the patient in the most comfortable position - Education to the patient and the family on the management of the gastrotomy tube to avoid infection 5.

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In this section you have learned about the macronutrients: carbohydrates buy provigil 200 mg line, fats provigil 100 mg online, proteins, water and fibre, and how they nourish the body. You are now going to learn more about vitamins and minerals, the important micronutrients. They are grouped together because, as their name implies, they are a vital factor in the diet. Classifications of vitamins Vitamins are classified into two groups: Fat soluble vitamins (vitamins A, D, E and K) are soluble in fats and fat solvents. Water soluble vitamins (vitamins B and C, and folic acid) are soluble in water and so they cannot be stored in the body. However, an adequate micronutrient intake can only be achieved through sufficient intake of a balanced diet that includes plenty of fruits and vegetables. Vitamins Function Food sources Vitamin A Night vision Breastmilk, tomatoes, cabbage, Epithelial cells form the thin layer Healing epithelial cells lettuce, pumpkins of tissue lining the gut, Normal development of teeth Mangoes, papaya, carrots respiratory and genitourinary and bones Liver, kidney, egg yolk, milk, systems. Vitamin K For blood clotting Green leafy vegetables Fruits, cereals, meat, dairy products B complex Metabolism of carbohydrates, Milk, egg yolk, liver, kidney proteins and fats and heart Whole grain cereals, meat, whole bread, fish, bananas Scurvy is a disease caused by Vitamin C Prevention of scurvy Fresh fruits (oranges, banana, vitamin C deficiency which leads mango, grapefruits, lemons, Aiding wound healing to sore skin, bleeding gums and potatoes) and vegetables internal bleeding. Examples of minerals include calcium, iron, iodine, fluorine, phosphorus, potassium, zinc, selenium, and sodium. Minerals Function Food sources Calcium Gives bones and teeth rigidity and Milk, cheese and dairy products strength Foods fortified with calcium, e. The vitamins and minerals that make up micronutrients have a crucial role in enabling the body to function properly. Your role as a Health Extension Practitioner is to advise people in your community to have a balanced diet that includes micronutrients. You will learn more about micronutrients in Study Session 7, in particular the impact of deficiencies in vitamin A, iron and iodine on individuals and communities. In this section we’ll discuss what a balanced diet is and the benefits of a balanced diet. It is important that you know enough to be able to recommend a balanced diet for the people in your community. Eating a balanced diet means choosing a wide variety of foods and drinks from all the food groups. It also means eating certain things in small amounts, namely saturated fat, cholesterol, simple sugar, salt and alcohol. The goal is to take in all of the nutrients you need for health at the recommended levels and perhaps restrict those things that are not good for the body. Then you can decide if people need help or food from the other food groups further support or information to improve the balance of things they eat. It helps us identify the food groups people should combine in order to make a balanced diet. The food groups at the top of the pyramid should be eaten in moderation (small amount) but food groups at the bottom of the pyramid should be eaten in larger amounts. For example, ‘injera’ is the staple diet in many sites, maize in other areas, and ‘kocho’ in the southern part of the country. These foods are usually cheap, and provide most of the energy, protein and fibre in a meal, as well as some vitamins. For example, legumes such as peas, beans and lentils add protein, iron and other minerals and fat; green and yellow vegetables and fruits add vitamins A and C, folate, and fibre. A diet which is composed of staples, legumes and vegetables or fruits is a good, balanced diet because this combination of foods will provide most of the nutrients that the people in your community need. Animal sources are good because they contain plenty of protein, have high energy (due to the fats), and the iron is easily absorbed compared with the iron sourced from plants. Therefore adding small amounts of animal products like meat, milk and eggs to staples, legumes and vegetables will improve the balanced diet. As well as protein, animal foods will also provide fat (for energy) and vitamins (especially vitamin A and folate), iron and zinc.

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However buy provigil 200 mg, depending on the nature of the disease and the general condition of the baby discount 200mg provigil amex, decision may be taken to handle the baby in centres with less than optimal facilities in Metro cities if there is a genuinely good cause to believe that good surgical and post-operative care can be extended to the child without much detriment to the baby c. In any situation, after the initial resuscitation, if the general condition of the baby is poor or if there is a possible necessity of ventilatory support or specialised treatment, it will be necessary to shift the baby to a higher centre where such facilities are available, ensuring safe transportation of the baby 17. Early involvement of a pediatric surgeon and regular co-ordination with him/ her 3. Carry out the orders of the Pediatrician / Pediatric Surgeon in charge of the patient 3. To ensure that all the orders are properly carried out by the nursing and other paramendical personnel 4. Prompt assessment of the baby on referral and to formulate an appropriate plan of action 2. Co-ordinating with the anesthetist and the other Operation Theatre personnel for the proposed surgery 3. Performing the appropriate surgery and to make reasonable efforts for a smooth post- operative recovery. Post-operative care & Daily assessment with regard to the post-operative recovery 5. Take decisions with regard to the daily progress and further interventions as and when indicated iv. Early involvement of a pediatric surgeon and regular co-ordination with him/ her 3. Improper and inadequate management of seizures could be one of the major reasons behind this phenomenon. Myoclonic seizures carry the worst prognosis in terms of neuro- developmental outcome and seizure recurrence. Common metabolic causes of seizures include hypoglycemia, hypocalcemia, and hypomagnesemia. Cerebral dysgenesis and neuronal migration disorders are rare 99 causes of seizures in the neonatal period. Screening and management of polycythemia and hypoglycemia can prevent seizure occurrence due to these reasons. Avoiding animal mlk feeding by exclusive breastfeeding may reduce seizures due to late onset hypocalcemia. History Seizure history: A complete description of the seizure should be obtained from the parents/attendant. History of associated eye movements, restraint of episode by passive flexion of the affected limb, change in color of skin (mottling or cyanosis), autonomic phenomena, and whether the infant was conscious or sleeping at the time of seizure should be elicited. The day of life on which the seizures occurred may provide an important clue to its diagnosis. While seizures occurring on day 0-3 might be related to 100 perinatal asphyxia, intracranial hemorrhage, and metabolic causes, those occurring on day 4-7 may be due to sepsis, meningitis, metabolic causes, and developmental defects. Antenatal history: History suggestive of intrauterine infection, maternal diabetes, and narcotic addiction should be elicited in the antenatal history. A history of sudden increase in fetal movements may be suggestive of intrauterine convulsions. Perinatal history: Perinatal asphyxia is the commonest cause of neonatal seizures and a detailed history including history of fetal distress, decreased fetal movements, instrumental delivery, need for resuscitation in the labor room, Apgar scores, and abnormal cord pH (<7) and base deficit (>10 mEq/L) should be obtained. Use of a pudendal block for mid-cavity forceps may be associated with accidental injection of the local anesthetic into the fetal scalp. Family history: History of consanguinity in parents, family history of seizures or mental retardation and early fetal/neonatal deaths would be suggestive of inborn errors of metabolism. Examination Vital signs: Heart rate, respiration, blood pressure, capillary refill time and temperature should be recorded in all infants. General examination: Gestation, birth-weight, and weight for age should be recorded as they may provide important clues to the etiology – for example, seizures in a term ‘well baby’ may be due to subarachnoid hemorrhage while seizures in a large for date baby may be secondary to hypoglycemia. The neonate should also be examined for the presence of any obvious malformations or dysmorphic features. A detailed neurological examination should include assessment of consciousness (alert/drowsy/comatose), tone (hypotonia or hypertonia), and fundus examination for chorioretinitis.

Perioperative care encompasses both pre and post operative care of the patient with congenital heart disease order provigil 200 mg without prescription. Although many infants and children with congenital heart defects are managed as outpatients until their repairs order 100 mg provigil otc, some infants or older children with severely abnormal physiology require stabilization and critical care prior to surgery. Many of the basic principles of cardiac intensive care apply to both pre and post operative care and will be considered in this chapter. In addition to supportive care and stabilization, pre operative management includes thorough evaluation of the anatomy and physiology of the heart and the physiologic status of the patient as a whole so that appropriately planned and timed surgery can take place. Basic principles of pediatric critical medical and nursing care remain relevant in the pediatric congenital cardiac patient. Pediatric cardiac patients are cared for in specialized cardiac intensive care units and in multidisciplinary intensive care units. There is some data that institutions that perform more surgeries have improved outcomes (info here—based on surgeon, unit, hospital?? Regardless of the focus of the unit, a commitment to ongoing education and training, as well as a collaborative and supportive environment is essential. We feel strongly that a unit dedicated to the care of infants and children is best able to care for these patients (down on the adult units caring for kids). Oxygen delivery is therefore primarily dependent on systemic cardiac output, - 58 - hemoglobin concentration, and oxygen saturation. Stroke volume is in turn dependent on preload, afterload, and myocardial contractility. Both pulmonary blood flow (Qp) and systemic blood flow (Qs) are determined by these fundamental forces. In the patient with two ventricles, ventricular interdependence, or the affect of one ventricle on the other, may play a role in pulmonary or systemic blood flow. In some situations, including the post operative state, the pericardium and restriction due to the pericardial space may also play a role in ventricular output. When evaluating the loading conditions of the heart and myocardial contractility, it is important to consider the two ventricles independently as well as their affect on one another. In previously healthy pediatric patients without heart disease, right atrial filling pressures are commonly assumed to reflect the loading conditions of the left as well as the right ventricle. Pre-existing lesions and the affects of surgery may affect the two ventricles differently. For example, the presence of a right ventricular outflow tract obstruction will lead to hypertrophy of the right ventricle. That right ventricle will be non-compliant, and the right atrial pressure may therefore not accurately reflect the adequacy of left ventricular filling. Oxygen content (CaO2) is primarily a function of hemoglobin concentration and arterial oxygen saturation. Thus, patients who are cyanotic can achieve adequate oxygen delivery by maintaining a high hemoglobin concentration. Arterial oxygen saturation is commonly affected by inspired oxygen content, by mixed venous oxygen content of blood, by pulmonary abnormalities, and by the presence of a R to L intracardiac shunt. Arterial oxygen content in the patient with a single ventricle and parallel pulmonary and systemic circulations will depend on the relative balance between the circulations as well. In the patient with intracardiac shunt or the single ventricle patient, arterial oxygen content is also affected by the relative resistances of the pulmonary and systemic circuits, as this determines how much blood flows through the lungs relative to the systemic output. Low mixed venous oxygen content contributes to desaturation and suggests increased oxygen extraction due to inadequate oxygen delivery, which in turn is either due to inadequate systemic cardiac output or inadequate hemoglobin concentration. A thorough understanding of these fundamental principles of cardiac output and oxygen delivery is essential for the perioperative care of the patient with congenital heart disease. General Principles of Anatomy and Pathophysiology Affecting Pre-operative and Post- operative Management An understanding of the anatomy and pathophysiology of the congenital cardiac lesion under consideration allows one to determine the pre-operative care or resuscitation needed and to predict the expected post-operative recovery. Acyanotic Heart Disease Children with acyanotic heart disease may have one (or more) of three basic defects: 1) left-to-right shunts (e. These lesions may lead to decreased systemic oxygen delivery by causing maldistribution of flow with excessive pulmonary blood flow (Qp) and diminished systemic blood flow (Qs) (Qp/Qs >1), by impairing oxygenation of blood in the lungs caused by increased intra and extravascular lung water, and decreasing ejection of blood from the systemic ventricle. Maldistribution of Flow: Qp/Qs >1 In infants with left-to-right shunts, pulmonary blood flow (Qp) increases as pulmonary vascular resistance (Rp) decreases from the high levels present perinatally. As pulmonary flow increases, left ventricular volume overload may occur with cardiac failure, decreased systemic output, pulmonary congestion and edema. If pulmonary pressures exceed systemic pressures, right to left shunting predominates and the patient becomes cyanotic.

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