Paediatric elbow trauma

You can tell the approximate age of a child from the degree of bone replacement of cartilage on x-ray. Approximately :

• Capitellum 'appears' at 2
• Radial head at 4
• Medial condyle at 6
• Trochlea at 8
• Olecranon at 10
• Lateral condyle at 12 years of age

The acronym CRMTOL is used to describe the usual order of appearance of all 6 elbow centers: capitellum, radial head, medial epicondyle, trochlea, olecranon, and lateral epicondyle.

References

• http://www.pediatric-orthopedics.com/Topics/Bones/Humerus/humerus.html
• Elbow Trauma, Pediatric on eMedicine
  

Sedation tips

• Don't use midazolam and olanzapine together as it can cause rapid onset respiratory depression. Clonazepam and olanzipine is a better combination.
• Chlorpromazine is also good. Non-addictive, and comes as a liquid.
  

Blood Products timing

RBCs 1 unit q4h
FFP 1 unit q1h
Platelets 1 unit q30minutes

CTPA and renal function

GFR < 60 is borderline.

Home Oxygen

Criteria to qualify:

• pO2 < 55
• SaO2 < 90% RA
• Non-smoker!
  

Can be regular/PRN.

Hartmann's (Compound Sodium Lactate)

Components (in mmols):

• Na 129
• K 5
• Ca 2
• Cl 109
• bicarb 29
  

Peutz–Jeghers syndrome

• Peutz–Jeghers syndrome is also known as hereditary intestinal polyposis syndrome.
• An autosomal dominant genetic disease characterized by the development of benign hamartomatous polyps in the GIT and hyperpigmented macules on the lips and oral mucosa.
• Prevalence of approximately 1 in 100,000 to 200,000 births.
  

Diagnosis

Need 2 of 3 of:

• Family history
• Mucocutaneous lesions causing patches of hyperpigmentation in the mouth and on the hands and feet.
  
  • Oral pigmentations are the first to appear and play an important part in early diagnosis. Intraorally, they are most frequently seen on the gingiva, hard palate and inside of the cheek. The mucosa of the lower lip is almost invariably involved as well.
• Hamartomatous polyps in the gastrointestinal tract. These are benign polyps with an extraordinarily low potential for malignancy.
• Mutation in the tumour supressor gene STK11 on chromosome 19.

Natural history

• Most patients will develop melanotic macules during the first year of life.
• Intussusception usually first occurs between the ages of six and 18 years old.
  
• Most people will have developed some form of neoplastic disease by age 60.
• Cumulative lifetime cancer risk begins to rise in middle age.
• Cumulative risks by age 70 for all cancers, gastrointestinal (GI) cancers, and pancreatic cancer are 85%, 57%, and 11%, respectively.

References

• http://en.wikipedia.org/wiki/Peutz-Jeghers_syndrome
• http://www.answers.com/topic/peutz-jeghers-syndrome
  

IV Fluids

Standard fluid regime for NBM patients:

• N/2 * 2 bags
• 4 % dextrose + N/5 + 30mmol KCl

In terms of fluid requirements,

• 65% of body is water (TBW)
• 2/3 of this is intracellular, 1/3 extracellular

Ways you can lose electrolytes:

• Vomiting → loss of K
• Diarrhoea→ loss of K
• Sweat→ loss of NaCl
• Burns → loss of protein and Na
• Third space losses → loss of NaCl + H20

Ways to assess dehydration:

• Urine dipstick - concentration
• ↑ Ur and ↑ Na

Correction of hypernatremia begins with a calculation of the fluid deficit. Predicted insensible and other ongoing losses are added to this number and the total is administered over 48 hours. Recheck serum electrolyte levels frequently during therapy. To avoid cerebral edema and associated complications, the serum sodium level should be raised by no more than 1 mEq/L every hour. In patients with chronic hypernatremia, an even more gradual rate is preferred.

Free Water Deficit (L) = Body Weight (kg) X Percentage of Total Body Water (TBW) X ([Serum Na / 140] - 1)

Percentage of TBW should be as follows:

• Young men - 0.6%
• Young women and elderly men - 0.5%
• Elderly women - 0.4%

Example:

• A serum sodium level of 155 in a 60-kg young man represents a fluid deficit of 60 X 0.6 X ([155 / 140] - 1) or 3.9 L
  

• With another 900 mL of insensible losses, the patient requires 4.8 L of fluid in the next 48 hours, resulting in an infusion rate of 100 mL/h.

SIADH

• Pure water depletion and ↑ Na → use 4% D + N/5 to treat it.
• Stimulating the bowel e.g. abdo surgery → release of ADH → SIADH

References

• http://www.merck.com/mmpe/print/sec12/ch156/ch156e.html
• http://emedicine.medscape.com/article/766683-treatment
  

Psych progress notes template

Day X
Meds

Subjective

• What they tell you
  

Objective

• MSE

Assessment

• What do they have? Are they getting better/worse?
  

Plan

1. care level
2. leave
• unescorted x __ hrs
• escorted x __ hrs with ____
3. Medications - any new ones/stopped ones/changes in doses?
   
4. Investigations
5. Other things that need to be done e.g. call GP, family members etc..