Tuesday, July 18, 2017

Approach To A Child Presenting With Urinary Retention

Acute urinary retention is relatively infrequent in children. There are a variety of causes that are poorly defined in the literature, and they differ greatly from those seen most frequently in adults.

Urinary retention means an inability to void or unable to empty the bladder.

Taking the History

When a child presents with the complains of inability to void a detailed history is required in order to reach the diagnosis and then manage accordingly.


1. If the patient is toilet trained?

2. Is patient constipated

3. Is there pain on urination or fever

4. Any history of trauma

5. Past history of UTI

6. Any history suggestive of sexual abuse

7. Any medications currently in use

Physical Examination
After a detailed history relevant physical examination is necessary that may include
  • General Physical Appearance: the child may appear ill looking and uncomfortable.
  • Abdomen: Tender , tense smooth suprapubic mass usually indicates a distended urinary bladder.
  • Genitalia: Phimosis ( if uncircumcised) , meatal stenosis and erythema of perpuse or glans may represent acute balanoposthitis or erythema may indicate sexual abuse.
  • Neurological examination: is needed to assess the sensation in the perineal area.

Asthma – Management in Emergency Room

A child with acute attack of asthma will usually present with difficulty breathing, cough, wheezes and cyanosis.

Initial Assessment
Assess the Heart Rate, Respiratory Rate, O2 saturation, Peak expiatory flow rate, Use of accessory muscles, Pulsus paradoxus ( more than 20 mmHg difference in systolic B.P for inspiratory versus expiratory phase ) , Dyspnea, Alertness, Colour.

Initial Management

1. Give O2 to keep saturation > 95%.

2. Administer inhaled B- agonists: Nebulized albuterol 0.05 to 0.015 mg/kg/dose every 20 minutes or continuously depending on the condition.

3. Other nebulized bronchodilators that can be used include ipratropium bromide 0.25 to 0.5 mg.

4. If the air movement is poor or the patient is unable to cooperate with a nebulizer give epinephrine 0.01 ml / kg SC . It can be given every 15 minutes upto 3 doses.

5. Starting Steroids: If there is no response after one nebulized treatment or if the patient is steroid dependent or had a recent emergency depertment visit or an ICU care needed start prednisolone 2 mg/kg /day divided 6 hrly.

Blood Components and Their Uses in Pediatrics

Many blood products are available but they have never been safe as they can transmit diseases. For this reason children should only recieve blood products when othe conservative measures have failed.

Red Blood Cells ( RBCs )
Indicated in cases of severe anemia usually when Hb is < 7 gm%. or when there is acute , severe, traumatic blood loss.

Different types include:
  • Whole Blood ( rarely used )
  • Packed RBCs = whole blood less 70% of plasma , most commonly used
  • Leukocyte poor RBCs= for pateints with history of febrile reaction to blood products or who will recieve many transfusions
  • Washed RBCs = to prevent host-versus graft disease in Ig A deficient recipients

Respiratory Distress Syndrome Of Newborns - A Brief Discussion

Respiratory Distress Syndrome of the newborns (RDS) also known as hyaline membrane disease is a breathing disorder of premature newborns in which the air sacs (alveoli) in a newborn’s lungs do not remain open because the production of a substance that coats the alveoli (surfactant) is absent or insufficient. This disease is mainly confined to premature babies. Insufficient surfactant leads to alveolar collapse; re-inflation with each breath exhausts the baby, and respiratory failure follows. Hypoxia leads todecreased cardiac output, hypotension, acidosis and renal failure. It is the
major cause of death from prematurity.

Risk factors:

  • Preterm babies ( 91%risk if born at 23–25 weeks; 52% risk  if 30–31 weeks.)  
  • Maternal diabetes,
  • Male babies, 
  • 2nd twin, 
  • Caesarean deliveries.

Clinical Signs 
  • Respiratory distress shortly after birth (within first 4 hours)
  • tachypnoea ( respiratory rate >60/min),
  • grunting, 
  • nasal flaring, 
  • intercostal recession and 
  • cyanosis. 
Chest X ray shows diffuse granular patterns (ground glass appearance) ± air bronchograms.

Saturday, July 15, 2017

Heel Stick Capillary Blood sampling

Heel stick is a minimally invasive and easily accessible way of obtaining capillary blood samples for various laboratory tests, especially newborn screens and glucose levels.


For the collection of blood in neonates and infants.


Edematous skin puncture site
Children older than 1 year of age.

Materials need for the procedure

  • Sterile gauze
  • Alcohol wipe
  • Heel warmer
  • Automatic lancet device
  • Appropriate containers for blood sample
  • Adhesive bandage
  • Sterile gloves

1. Warm the infant’s heal for approximately 5 minutes. With gloved hands , cleanse the area with alcohol wipe. Hold the foot firmly with the leg in a tucked – flexed position

2. Grasp infant’s heel in a moderately firm grip, with the fore finger at the arch of the foot and the thumb below the puncture site at the ankle.

Approach to a Child With Eye Discharge and Swelling

Conjunctivitis is a common infection especially among children under five. Children with conjunctivitis must be kept home from school or day care until the discharge from their eyes has stopped. This will prevent the spread of infection to other children. The incidence of conjunctivitis decreases with age.
Conjunctivitis leads to:
  • Eye irritation and redness
  • Excessive tears in the eyes
  • A discharge with pus
  • Swelling of the eyelids
  • Photophobia
History Taking
Age of the child is important in determining the etiology of conjuctivitis. In newborns typical cause is chemical, chalmyadial or bacterial. In older children bacteria , viruses and allergies are more likely causes.

Onset of Symptoms
Time of onset is especially important in the neonatal period. With chemical conjunctivitis inflammation begins a few hours after drops have been placed and lasts for 24 to 36 hrs. Gonococccol conjunctivitis develops between 2 and 5 days of life.

Characteristic of discharge

  • Viral conjunctivitis usually causes watery or serous discharge.
  • Bacteria causes purulent or mucopurulent discharges.
  • Allergies produce serous or mucoid discharge often very stringy.
Associated Symptoms
Viral conjunctivitis is often associated with upper respiratory symptoms or other systemic complains like pharyngitis . Preauricular adenopathy and rashes may also be present. With vesicles or corneal ulceration HSV must be rules out. Pain on movement of the eyes is never normal and orbital cellulitis should be ruled out.