Approach to Practical Pediatrics, 2E (Manish Narang) (2011).pdf

Approach to Practical Pediatrics i. r ss n is a er. p iv p /: / tt p h  i. r...

Approach to Practical Pediatrics i. r ss n is a er. p iv p /: / tt p h  i. r ss n is a er.p iv p /: / tt p h  Approach to Practical Pediatrics SECOND EDITION i. r ss n is a Manish Narang MBBS MD (Pediatrics) r Lecturer e Department of Pediatrics University College of Medical Sciences and GTB Hospital p New Delhi, India. iv p /: / tt p h ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi St Louis Panama City London Published by i. r s Jaypee Brothers Medical Publishers (P) Ltd s Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India n Phone: +91-11-43574357, Fax: +91-11-43574314 is a Offices in India Ahmedabad, e-mail: [email protected] Bengaluru, e-mail: [email protected] Chennai, e-mail: [email protected] r Delhi, e-mail: [email protected] e Hyderabad, e-mail: [email protected] Kochi, e-mail: [email protected] p Kolkata, e-mail: [email protected]. Lucknow, e-mail: [email protected] Mumbai, e-mail: [email protected] iv p Nagpur, e-mail: [email protected] Overseas Offices North America Office, USA, Ph: 001-636-6279734, e-mail: [email protected] /: / [email protected] Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: [email protected], Website: www.jphmedical.com Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: [email protected] tt p Approach to Practical Pediatrics © 2011, Jaypee Brothers Medical Publishers h All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 2007 Second Edition: 2011 ISBN 978-93-5025-093-8 Typeset at JPBMP typesetting unit  Dedicated to i. r ss n is a MY MOTHER er. p Late Dr (Mrs) CK NARANG iv p All that I am and ever hope to be, I owe to my angel Mother /: / tt p h  i. r ss n is a er.p iv p /: / tt p h  Preface to the Second Edition You can score 75% marks by reading just 25% but the question is which 25%. It is with the concept of i. r finding this 25% that this book was written. I have written, what I would have loved to read as an undergraduate and postgraduate student in pediatrics. This book reflects a simplified approach to clinical cases in pediatrics. s New chapters packed with information and practical tips have been added on Anthropometry, Health s Indicators, High-risk Newborns, and Leukemia. Detailed and updated information have been added n about asthma devices in chapter on Instruments while vaccine controversies and newer vaccines have been discussed in chapter on Immunization. This book also covers new ground about differential diagnosis is a of hepatosplenomegaly, management of thalassemia and simplified approach to paraplegia. Chapter on Protein Energy Malnutrition (PEM) includes recent IAP/WHO guidelines on management of severely malnourished child while chapter on Cardiovascular System includes simplified approach for diagnosis r of congenital heart diseases (CHD), recent guidelines on management of CHD and rheumatic heart disease in children. e This book is an outcome of my personal difficulties encountered during case presentations. I hope p this book helps readers to achieve my goal of learning maximum without wasting time in searching. answers from different sources. iv p I would like to hear from my readers regarding additions, omissions or just good ideas for further inclusion. These may be e-mailed to [email protected] /: / Manish Narang tt p h  i. r ss n is a er.p iv p /: / tt p h  Preface to the First Edition This text approaches diagnosis the way clinicians do—by symptom rather than disease entity. There is i. r no well-structured or standardized textbook on Practical Pediatrics. Practical material of pediatrics is often scanty and theoretical. It is in this background that I decided to translate the agreed contents of bedside clinics in pediatrics into an easily readable material. It combines clinical experience and evidence- s based strategies to guide clinicians through differential diagnoses and then to a specific diagnosis, then s to appropriate therapy for common pediatric ailments. n Special skills required in taking Birth history/Dietary history/Developmental history/Immunization history are discussed in separate chapters. The book covers much new ground and reflects the approach is a of pediatrics while taking clinical cases. Chapters on Antibiotic Therapy/Legal Aspects/Newer Guidelines of American Academy of Pediatrics—2005 for neonatal resuscitation have been written keeping in mind the needs of postgraduates while chapters like Instruments/Drug Therapy/Various Cases have been r written keeping in mind both postgraduates and undergraduates. This book is an outcome of personal experience and is a vital presentation from which a student can e learn maximum without wasting time in searching answers from different books. It is the next best p thing to attending ward teaching rounds!. I welcome comments concerning errors, contents and critical thoughts for future editions. These iv p may be e-mailed to [email protected] Manish Narang /: / tt p h  i. r ss n is a er.p iv p /: / tt p h  Acknowledgments This is a befitting occasion for me to thank my mother Late Dr CK Narang and Late Mrs and Mr RK i. r Virmani for their immeasurable contribution to my life. I sincerely wish to acknowledge the constant source of inspiration I have received from my teachers who have been instrumental in teaching me various aspects of pediatrics. It gives me immense pleasure s to express my gratitude to Dr MMA Faridi, Professor and Head, Department of Pediatrics, UCMS and s GTBH for giving me stimulating suggestions. I would like to asseverate my gratitude for Dr OP Kalra n (Principal, UCMS); Dr Sunil Gomber (Professor, UCMS); Dr Piyush Gupta (Professor, UCMS), Dr Anup Mohta (Professor and Head, CNBC) and Dr. Dheeraj Shah (Reader, UCMS) for their untiring is a support. I feel honored and privileged to have worked under their able guidance. I must thank all my patients without whom this work would not have been possible. I wish to express my sincere and heartful thanks to Chaitanya Das and Rahul Dhaneja, ND Comm services in r their meticulous computerized paging out of this book. e Special thanks are due to my family—my grandmother Smt Kaushalya Devi Narang; my father p Dr Keshav Kumar Narang; my beloved wife Dr Shiva and loving daughter Maanya; and gems of my. family, my sisters Dr Sheetal and Dr Rashim; brother-in-laws Dr Peeyush and Dr Vishal; for their forbearance and whose share of time I selfishly usurped during preparation of manuscript. I also sincerely iv p wish to express my appreciation to my dear ones, Dr BK Mehrotra, Mrs Seema and Mr Rajiv Mehrotra and Late Dr Harsh Narang. /: / tt p h  i. r ss n is a er.p iv p /: / tt p h  Contents SECTION -I i. r BASICS OF PRACTICAL PEDIATRICS s CHAPTER -1 : INSTRUMENTS 3-29 s Laryngoscope 3; Endotracheal Tube 4; Self-inflating Bag 5; Face Mask 6; Oxygen Mask 6; Nasal n Oxygen Catheter 7; Acrylic Oxygen Hood 8; Infant Feeding Tube 9; Suction Catheter 10; Umbilical is a Catheter 10; Dileys Mucus Extractor 11; Tongue Depressor 11; Tuberculin Syringe 11; Inhalers 12; Metered Dose Inhaler 12; Dry Powder Inhaler (DPI) 14; Nebulizer Chamber 14; Spacer 15; Bone Marrow Aspiration Needle 16; Bone Trephine Biopsy 16; Lumbar Puncture Needle 17; Vim-Silverman’s r Needle 17; Trucut Biopsy Needle 17; Three Way 18; Microdrip Set 19; Blood Set 19; Guedel Airway 19; Intravenous Cannula 20; Sphygmomanometer (BP Apparatus) 20; Condom Catheter 21; e Cord Clamp 21; Respiratory Exerciser 21; Urine Collection Bag 22; Infantometer 22; Sahli’s Hemoglo- binometer 22; Wintrobe’s Tube 24; Westergren Tube 24; Neubauer’s Chamber 25; RBC Pipette 25;. p Growth Chart 26 iv p CHAPTER - 2: DRUGS 30-48 ORS (Oral Rehydration Solution) 30; Sodium Bicarbonate 34; Ringer Lactate 34; 25% Glucose 35; /: / Mannitol (20% Solution) 36; Calcium Gluconate 36; Potassium Chloride (KCI) 36; Aminophylline 37; Adrenaline 38; Dopamine 38; Dobutamine 39; Atropine 39; Furosemide 40; Digoxin 40; Vitamin D 41; Vitamin A 42; Vitamin K 43; Diazepam 43; Phenobarbitone 43; Phenytoin 44; Phosphenytoin 45; tt p Midazolam 45; Penicillin 46; Methyl Prednisolone 47; Difference between Prednisolone and Methyl Prednisolone 48 h CHAPTER - 3: NEONATAL RESUSCITATION 49-59 Introduction 49; Basics of Asphyxia 49; Response to Birth 51; Initial Steps of Resuscitation 51; Evaluation 51; Bag and Mask Ventilation 52; Chest Compressions 52; Endotracheal Intubation 53; Neo- natal Resuscitation Guidelines 2005 56; Medications 59; Epinephrine 59; Crystalloids 59; Soda Bicar- bonate 59; Postresuscitation Care 59 CHAPTER - 4: IMMUNIZATION 60-89 Immunization History 60; BCG Vaccine 62; Oral Polio Vaccine 64; Injectable Polio Vaccine (IPV) 64; DTwP Vaccine 66; DTaP Vaccine (Acellular Pertussis Vaccine) 67; DT Vaccine 67; xiv Approach to Practical Pediatrics Tetanus Toxoid 67; Tetanus Immunoglobulin (TIG) 68; TD Vaccine (Tetanus, Diphtheria Toxoid) 68; Tdap Vaccine 68; Measles Vaccine 68; MMR Vaccine 70; Mumps Vaccine 71; Rubella Vaccine 71; Hepatitis B Vaccine 71; Hepatitis B Immunoglobulin 72; Meningococcal Vaccine 73; Pneumococcal Vaccine 74; Influenza Vaccine 76; Rabies Vaccine 76; Rabies Immunoglo- bulin 77; H. Influenzae-b Conjugate Vaccine 77; Typhoid Vaccine 78; Chickenpox Vaccine 80; Hepatitis A Vaccine 81; Rotavirus Vaccine 8; Human Papilloma Virus (HPV) Vaccine 83; Combination i. r Vaccines 84; Cold Chain 84; Edible Vaccines 87; Immunization in Special Circumstances 87 CHAPTER - 5: ANTIBIOTIC THERAPY 90-94 s Empirical Initial Antimicrobial Therapy 90; Postoperative Empirical Antibiotics 92; Fungal s Infections 92; Liver Failure 92; Vancomycin 93; Carbepenems 93; Monobactams 93; Newer n Macrolides 94; Quinolones 94; Gram Negative Resistant Infections Including Pseudomonas Infections 94; Other Newer Antibiotics 94 is a CHAPTER - 6: DIFFERENTIAL DIAGNOSIS OF ABNORMAL SIGNS 95-100 r Bulging Anterior Fontanel 95; Craniotabes 95; Bossing of Skull 95; Papilledema 95; Blue Sclerae 96; Setting Sun Sign 96; Cataract 96; Cat’s Eye 96; Hypertelorism 96; Ocular Hypotelorism 96; Exoph- e thalmos 97; Ptosis 97; Mongoloid Slant 97; Antimongoloid Slant 97; Low Set Ears 97; Micrognathia 97; Macroglossia 97; Gum Hyperplasia 98; Delayed Dentition 98; Trismus 98; Oral p Thrush 98; Macrocephaly 98; Short Neck 98; Neck Rigidity 98; Costochondral Beading 99;. Opistotonus 99; Micropenis 99; Abnormalities of Testicular Size 99; Cafë-au-lait Spots 99; Hemihyper- iv p trophy 99; Pigeon-Shaped Chest 100; Scoliosis 100 CHAPTER - 7: DIETARY HISTORY 101-104 /: / Dietary history 101; Healthy feeding habit for infants 102; Characteristics of ideal complementary food 102; Prolactin reflex 104; Oxytocin reflex 104; Factors affecting mother’s reflexes 104 tt p CHAPTER - 8: DEVELOPMENTAL HISTORY 105-111 Developmental History 105; Methods Standardized for Assessment of Development in Children 106; Target Milestones 107; Milestones 107; Fine Motor and Adaptive 108; Scribbling 108; Tower of h Cubes 108; Vision 108; Personal and Social 108; Language 109; Toilet Training 109; Eruption Sequence of Teeth 109; Permanent Teeth 109; Development of Localization of Sounds 109; Growth Standards 110; Which Charts to Use 110; Recommended Intervals and Parameters for Growth Charting 111; Growth Charting 111; Concept of Percentiles 111 CHAPTER - 9: FAMILY AND SOCIOECONOMIC HISTORY 112-115 Socioeconomic History 112; Family History 112; Stillbirth Rate 113; Perinatal Mortality Rate 113; Neonatal Mortality Rate 113; Post-neonatal Mortality Rate 113; Infant Mortality Rate 113; Types of Families 113; Overcrowding 113; Degree of Relationship 113; WHO Criteria for Diagnosis of Anemia 113; Millenium Development Goals 113  Contents xv CHAPTER - 10: GENERAL PHYSICAL EXAMINATION 116-125 Components of Head to Toe Examination 116; Clubbing 117; Cyanosis 117; Lymphadenopathy 118; Temperature 120; Pulse 121; Jugular Venous Pulse (JVP) 123; Jugular Venous Pressure 124; Pallor 125; Edema 125 i. r CHAPTER - 11: ANTHROPOMETRY 126-130 Anthropometry 126; Weight 126; Height 126; Head Circumference 127; Body Ratio—Upper s Segment/Lower Segment Ratio 127; Arm Span 127; Chest Circumference 127; Mid Arm Circumference 128; Skin Fold Thickness 128; Body Mass Index 128; Mid Parental Height 128; s Classification of PEM 128; Age Independent Anthropometric Indices 129 n CHAPTER - 12: HEALTH INDICATORS 131-135 is a Health Indicators 131; Mortality 131; Low Birth Weight (NFHS 3) 132; Immunization Coverage (NFHS 3) 132; Children with Diseases Taken to Health Facility 132; Treatment of Childhood Diarrhea With ORS (NFHS 3) 133; Anemia Status (NFHS 3) 133; Coverage of Anganwadi Centers r (NFHS 3) 133; Household Characteristics (NFHS 3) 133; Education (NFHS 3) 133; Caste/Tribe Status (NFHS 3) 133; Marital Status (NFHS 3) 134; Current Contraceptive Use (NFHS 3) 134; Antenatal Care e (NFHS 3) 134; Maternity Care (NFHS 3) 134; Child Nutritional Status (NFHS 3) 134; Nutritional Status p of Adults 134; National Family Health Survey (NFHS) 134; Sample Registration Survey 134. SECTION -II iv p LONG CASES IN PEDIATRICS /: / CHAPTER - 13: PROTEIN ENERGY MALNUTRITION (PEM) 139-151 History 139; General Physical Examination 141; Systemic Examination 141; Diagnosis 142; tt p Investigations 142; Treatment 142; Discussion 145 CHAPTER - 14: RENAL SYSTEM 152-164 h NEPHROTIC SYNDROME History 152; General Physical Examination 153; Systemic Examination 153; Diagnosis 155; Differential Diagnosis 155; Investigations 156; Treatment 156; Discussion 159 CHAPTER -15: CARDIOVASCULAR SYSTEM 165-192 CONGENITAL HEART DISEASE History 165; General Physical Examination 167; Systemic Examination 167; Diagnosis 169; Differential Diagnosis 169; Treatment 170; Discussion 172 xvi Approach to Practical Pediatrics RHEUMATIC HEART DISEASE History 178; General Physical Examination 180; Differential Diagnosis 181; Investigations 182; Treatment 182; Discussion 185 CHAPTER -16: RESPIRATORY SYSTEM 193-205 i. r PLEURAL EFFUSION History 193; General Physical Examination 194; Systemic Examination 195; Differential Diagnosis 196; Investigations 197; Treatment 198; Discussion 199 s PNEUMOTHORAX s Symptoms 203; General Physical Examination 203; Systemic Examination 203; Investigations 204; n Treatment 204; Discussion 205 is a CHAPTER -17: GASTROINTESTINAL SYSTEM 206-225 HEPATOSPLENOMEGALY r History 206; General Physical Examination 207; Systemic Examination 208; Diagnosis 210; Differential Diagnosis 210; Investigations 218; Discussion 219 p e CHAPTER -18: CENTRAL NERVOUS SYSTEM 226-290. TUBERCULOUS MENINGITIS (TBM) iv p History 226; General Physical Examination 227; Systemic Examination 228; Diagnosis 231; Differential Diagnosis 232; Investigations 232; Treatment 233; Discussion 234 /: / HEMIPLEGIA History 240; General Physical Examination 242; Systemic Examination 243; Diagnosis 245; Differential Diagnosis 245; Investigations 245; Treatment 245; Discussion 246 tt p PARAPLEGIA History 249;General Physical Examination 250; Systemic Examination 250; Diagnosis 252 Differential Diagnosis 252; Investigations 253; Treatment 254; Discussion 254 h HYDROCEPHALUS History 258; General Physical Examination 259; Systemic Examination 259; Diagnosis 259; Differential Diagnosis 259; Investigations 259; Treatment 259; Discussion 260 ACUTE FLACCID PARALYSIS History 262; General Physical Examination 263; Systemic Examination 264; Differential Diagnosis 266; Investigations 266; Treatment 267; Discussion 267 CEREBRAL PALSY History 270; General Physical Examination 272; Systemic Examination 272; Diagnosis 274; Differential Diagnosis 274; Investigations 274; Treatment 275; Discussion 275  Contents xvii NEURODEGENERATIVE DISEASES History 279; General Physical Examination 280; Systemic Examination 280; Investigation 280; Treatment 281; Differential Diagnosis 281; Discussion 283 FLOPPY INFANT History 285; Chief Complaints 285; General Physical Examination 286; Systemic Examination 286; i. r Diagnosis 287; Differential Diagnosis 287; Investigations 287; Discussion 289 SECTION- III ss SHORT CASES IN PEDIATRICS n CHAPTER -19: SHORT STATURE 293-300 is a History 293; General Physical Examination 294; Systemic Examination 295; Differential Dignosis 295; Investigations 296; Treatment 297; Discussion 297 r CHAPTER -20: DOWN’S SYNDROME 301-306 e History 301; General Physical Examination 302; Systemic Examination 302; Diagnosis 302; p Investigations 302; Treatment 302; Discussion 302. CHAPTER -21: RICKETS 307-314 iv p History 307; General Physical Examination 308; Diagnosis 309; Investigations 309; Treatment 309; Discussion 310 /: / CHAPTER -22: NORMAL NEONATE 315-324 History 315; General Physical Examination 316; Systemic Examination 317; Diagnosis 319; tt p Discussion 320 CHAPTER -23: HIGH–RISK NEONATE 325-329 h HIgh-risk Babies 325 CHAPTER -24: KALA-AZAR 330-336 History 330; General Physical Examination 331; Systemic Examination 331; Diagnosis 332; Differential Diagnosis 332; Investigations 333; Treatment 334; Discussion 335 CHAPTER -25: THALASSEMIA 337-351 History 337; General Physical Examination 338; Systemic Examination 338; Diagnosis 341; Differential Diagnosis 341; Investigations 341; Treatment 342; Discussion 343 xviii Approach to Practical Pediatrics CHAPTER -26: LYMPHOMA 352-358 History 352; Systemic Examination 354; Diagnosis 354; Differential Diagnosis 355; Investigations 355; Treatment 356; Discussion 357 CHAPTER -27: LEUKEMIA 359-365 i. r History 359; General Physical Examination 360; Systemic Examination 360; Diagnosis 361; Differential Diagnosis 361; Investigations 361; Treatment 363; Discussion 363 s CHAPTER -28: HYPOTHYROIDISM 366-372 s History 366; General Physical Examination 367; Systemic Examination 367; Diagnosis 367; n Differential Diagnosis 367; Investigations 367; Treatment 368; Discussion 369 is a CHAPTER -29: DUCHENNE MUSCULAR DYSTROPHY (DMD) 373-381 History 373; General Physical Examination 374; Systemic Examination 375; Diagnosis 337; Differential Diagnosis 377; Investigations 378; Management 378; Discussion 379 er CHAPTER -30: ATAXIA 382-386 p History 382; General Physical Examination 383; Systemic Examination 383; Differential Diagnosis 384;. Investigations 385; Treatment 385; Discussion 385 iv p CHAPTER -31: MENINGOMYELOCELE 387-392 History 387; General Physical Examination 388; Systemic Examination 389; Investigations 390; /: / Treatment 390; Discussion 391 SECTION- IV tt p MISCELLANEOUS STUDIES h CHAPTER -32: INVASIVE PROCEDURES 395-401 Lumbar Puncture (LP) 395; Intraosseous Cannulations 396; Heel Puncture 396; Subdural Tap 396; Bone Marrow Aspiration 397; Bone Trephine Biopsy 397; Liver Biopsy 398; Kidney Biopsy 399; Insertion of Nasogastric Tube 399; Abdominal Paracentesis 400; Pericardiocentesis 400; Suprapubic Tap 401 CHAPTER -33: LEGAL ACTS 402-407 The Juvenile Justice (Care and Protection of Children) Act, 2000 402; The Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 403; Adoption Act 404; The Infant Milk Substitutes, Feeding Bottles And Infant Foods Act, 1992 (IMS Act)405; Medical/Legal Pitfalls 407  Contents xix CHAPTER-34: TIMING OF SURGERY FOR COMMON PEDIATRIC CONDITIONS 408-409 Timing of Surgery 408 CHAPTER - 35: X-RAYS 410-421 i. r Respiratory System 410; Cardiovascular System 414; X-ray Skull 415; X-ray Bones 416; Gastrointestinal System 419; Retrograde Pyelography 420; CT Scan 420; MRI 420; Role of Radiation 421; Choice of Investigation 421 s CHAPTER - 36: ABG ANALYSIS 422-424 s Normal Values 422; Steps to ABG Analysis 422 n CHAPTER - 37: SOCIAL PROGRAMS 425-429 is a Nutritional Supplementation Programs in India 425; Vitamin A Prophylaxis Program 425; Prophylaxis Against Nutritional Anemia 425; Iodine Deficiency Disorder Control Program 426; Special Nutrition r Program 426; Balwadi Nutrition Program 426; Applied Nutrition Program 426; Mid-day Meal Program 426; Universal Immunization Program (UIP) 427; Child Survival and Safe Motherhood (CSSM) e Program 427; Maternal and Child Health 427; Reproductive and Child Health (RCH) 428; Integrated Child Development Services (ICDS) Scheme 428; Integrated Rural Development Program (IRDP) 429; p Adult Literacy Campaign 429; India Population Project (IPP) 429; International Programs 429. Appendix: Neonatal Resuscitation: 2010 American Heart Association Guidelines........................ 431 iv p Index.......................................................................................................................................... 433 /: / tt p h  i. r ss n is a SECTION–I er. BASICS pPEDIATRICS OF iv p PRACTICAL /: / tt p h  1 I NSTRUMENTS LARYNGOSCOPE (FIG. 1.1)  Laryngoscope is designed to be held in left hand – by both right and left handed persons. If held in right hand, the closed covered part of blade will block your view of glottis, as well as make insertion of ET tube impossible.  Turn on the laryngoscope light and hold the Laryngoscope in your left hand, between your thumb and first two or three fingers, with the blade pointing away from you. One or two fingers should be left free to rest on baby’s face to provide stability. SIZES Fig. 1.1: Laryngoscope  Zero (Preterm neonate) (For color version, see Plate 1)  One (Term neonate and infant)  The laryngoscope consists of a handle (which  Two (Children) also contains the batteries), blade and light  Three (Adolescent) source.  The blade can be either a straight blade (Miller) USES or a curved blade (Macintosh).  Straight blade is preferred for infants and Therapeutic toddlers since it provides better visualization  Endotracheal intubation of glottis but a curved blade is preferred for older children since its broader blade facilities  Suction catheter placement displacement of tongue and visualization of the  Magill forceps placement for foreign body glottis. removal 4 Section I: Basics of Practical Pediatrics  The endotracheal tube should have distance Diagnostic markers (in centimeter) for use as reference  Direct Laryngoscopy in papilloma, diphtheria points during placement and to facilitate detection of unintentional endotracheal tube STERILIZATION movement. 1 cm graduation markings are to ascertain insertion depth while 2 cm indicator  Autoclaving mark assists positioning of tube past the vocal cord. COMPLICATIONS  Vocal cord guide: Most ET tubes for neonates have a heavy black line set back from the tip  Injury like dislodgement of tooth which is meant to be aligned with the vocal  Bradycardia cords during tube insertion. This should position  Hypoxia the tip of the tube above the bifurcation of the trachea. ENDOTRACHEAL TUBE (FIG.1.2)  A cuffed endotracheal tube is generally indicated for children aged 8 to 10 years or older. In children younger than 8 to 10 years the normal anatomic narrowing at the level of the cricoid cartilage provides a functional cuff and so uncuffed tube is indicated.  Inflation is appropriate if an audible air leak is present when ventilation to a pressure of 20 to 30 cm H2O is provided. The absence of an air leak may indicate that the cuff is inflated excessively, that the endotracheal tube is too large, or that laryngospasm is occurring around Fig. 1.2: Endotracheal tube the endotracheal tube. (For color version, see Plate 1)  Simple visual estimates of appropriate endo- tracheal tube size can be made by choosing a The endotracheal tube should be sterile, tube with an outside diameter approximating disposable and constructed of translucent polyvinyl the diameter of the child’s little finger chloride with a radiopaque marker. (Table 1.1.)  An endotracheal tube of uniform internal diameter is preferrable to a tapered tube. Table 1.1: Size of ET tube  15 mm adapter is firmly affixed to the proximal end for attachment to a ventilating device. Tube size (mm) Weight (gm) Gestation Age (weeks)  The distal end of the endotracheal tube may 2.5 2 yrs = 4 4  Chapter 1: Instruments 5  Depth of insertion in cm (alveolar ridge to COMPLICATIONS midtrachea) for children older than 2 years can be approximated by:  Hypoxia/apnea Age in years  Injury  12 4  Pneumothorax Alternatively, the distance of insertion (in cm)  Bradycardia can be estimated by multiplying the internal  Obstruction diameter of the tube by 3. For example if i.d. = 4 mm SELF-INFLATING BAG (FIGS 1.3A AND B) Depth of insertion = 4 × 3 = 12 cm There are seven basic parts to a self-inflating bag: USES 1. Air inlet and attachment site for oxygen reservoir 2. Oxygen inlet General 3. Patient outlet  Mechanical ventilation 4. Valve assembly  Intermittent position pressure ventilation 5. Oxygen reservoir (IPPV) 6. Pressure release (pop-off) valve  Direct suctioning of trachea in meconium 7. Pressure manometer attachment site aspiration  Epiglottitis and life-threatening croup  Tetanus (for long-term basis, tracheostomy is preferable)  Diphtheria  Angioneurotic edema. Neonatal Resuscitation  Prolonged bag and mask ventilation  Ineffective bag and mask ventilation A  Diaphragmatic hernia.  Meconium aspiration syndrome. DRUGS GIVEN THROUGH ENDOTRACHEAL TUBE  Epinephrine  Atropine  Naloxone B  Isoproteronol Figs 1.3A and B: Self-inflating bag with oxygen reservior  Lignocaine (For color version, see Plate 1) 6 Section I: Basics of Practical Pediatrics  As the bag re-expands following compression,  Resuscitation masks have thin rims that are gas is drawn into the bag through a one way either cushioned or noncushioned. valve called air inlet.  The rim on a cushioned mask makes it easier  Every self-inflating bag has an oxygen inlet, to form a seal. It requires less pressure on new- which is a small nipple or projection to which borns face to obtain a seal. There is less chance oxygen tubing is attached. of damaging the newborn’s eyes.  The patient outlet is where gas exits from the  A mask with noncushioned rim, makes more bag to the baby and where the mask or difficult to obtain a seal, can damage the eyes, and can bruise the newborn’s face. endotracheal tube attaches.  Two shapes are available—Round and Anato-  When the bag is squeezed during ventilation, mically shaped. the valve opens, releasing oxygen/air to the  For the mask to be of correct size, the rim will patient. When the bag reinflates the valve is cover the tip of the chin, the mouth, and the closed. This prevents the patient’s exhaled air nose but not the eyes. Too large may cause from entering the bag and being re-breathed. possible eye damage. Too small will not cover  Most self-inflating bags have a pressure-release the mouth and nose and may occlude the valve (pop-off valve) which is generally set to nose. 30 to 40 cm H2O. If pressure greater than this is generated, the valve closes. OXYGEN MASK (FIG. 1.5)  Concentration of oxygen actually received by the patient without reservoir is 40%. High concentrations of oxygen can be achieved by using an oxygen reservoir. The concentration of oxygen achieved with a self-inflating bag with an oxygen reservoir attached will be between 90% and 100%.  Current recommendations are that a baby who requires resuscitation should be given a high concentration of oxygen (90 to 100%). FACE MASK (FIG. 1.4) Fig. 1.5: Oxygen mask (For color version, see Plate 1)  It has elongated design for visual patient assess- ment (cyanosis, regurgitation) with adjustable nose clip and elastic head strip which helps in proper positioning of mask on mouth and nasal area.  It also has exhalation ports in the side and between mask and face.  Lumen tube is provided to ensure continuous Fig. 1.4: Face mask (For color version, see Plate 1) flow of oxygen.  Chapter 1: Instruments 7  Proximal end of tube is fitted with soft funnel shaped connector for easy connection to oxygen source.  It should have low under mask volume (dead space) which will decrease the chances of rebreathing of exhaled gases. Uses  Administration of oxygen (with gas flow rate of 6-18 L/min, it provides 30-60% of oxygen)  Nebulization A  Provide supplemental oxygen for shorter period of time like transportation. DISADVANTAGES  Interference with feeding and suction proce- dures  If oxygen flow rate is less than 6 L/min, rebreathing of exhaled CO2.  Tightly fitted mask is not accepted by children and poorly fitted mask provide only 30-40 percent oxygen.  Variable FiO2 delivery. B Figs 1.6A and B: Nasal oxygen catheter NASAL OXYGEN CATHETER (For color version, see Plate 2) (FIGS 1.6A AND B)  It contains soft twin prong nasal tips to ensure ADVANTAGES equal volume of oxygen to both air passages and has star lumen main tube to avoid accidental  CPAP blockage.  Leaves mouth free for nutritional purpose.  Prongs are inserted into anterior nares and DISADVANTAGES oxygen is delivered into nasopharynx.  Sizes available: Adult and paediatric.  Does not provide humidified oxygen  Frequent displacement of prongs Use  Nasal mucosa injury. Administration of oxygen (with gas flow rate  Contraindicated in chonal atresia, deviated nasal of 2-4 L/ min, it provides 30-40% of oxygen). septum, nasal polyp. 8 Section I: Basics of Practical Pediatrics OTHER OXYGEN DELIVERY DEVICES ACRYLIC OXYGEN HOOD (FIG. 1.7)  Oxygen mask  Oxygen hood  Nasal cannula  Nasopharyngeal catheter. MONITORING OXYGEN THERAPY  Clinical assessment by color.  Pulse oximetry:  Recommended levels of oxygen saturation- 89-95%.  Pulse oximetry is based on measurement of the proportion of light transmitted by Fig. 1.7: Acrylic oxygen hood oxy-genated forms of hemoglobin; a (For color version, see Plate 2) sensor is placed over a finger, toe, earlobe, It is clear transparent acrylic shell that encompasses or the bridge of the nose, and a numerical the infant’s head with oxygen inlet nozzle and output is produced. port hole for easy access. With gas flow rate of  Pulse oximetry is generally accurate only 10-12 L/ min it provides 80-90% of oxygen. A for oxygen saturations greater than 80%; minimum gas flow of 4L/min is necessary to avoid therefore, arterial blood gas analysis is rebreathing of O2. recommended for oxygen saturations less than 80%. Uses  PaO2 estimation by arterial blood gas analysis  Hypoxemia  Transcutaneous oxygen measurement for SpO2 monitoring  Oxygen administration  Estimation of tissue oxygenation by estimation of serial lactate. ADVANTAGES Strategies to Improve Oxygenation  Humidification decreases the size of oxygen molecule, therefore, reaches alveoli easily.  Noninvasive  Humidification prevents drying of secretions as  Prone position dried secretions may block the airway.  Relief of pain  Well tolerated by infant.  Correction of anemia and shock  Allows easy access to rest of body.  Invasive  No risk of airway obstruction and gastric  Hyperbaric oxygen dilatation.  Conventional mechanical ventilation DISADVANTAGES  High frequency ventilation  Nitric oxide therapy  Prolonged exposure to humidified oxygen  Extracorporeal membrane oxygenation. increases the risk of cutaneous fungal infections.  Chapter 1: Instruments 9  Low temperature within enclosure system may the distance from the Bridge of the nose to the result in cold stress injury. tragus and from the tragus to the Xiphoid  Inadequate oxygen flow rate, may result in Process (the lower tip of the sternum). hypoxia or hypercapnia.  Insert the tube through the mouth rather than  Any opening in the enclosure may result in the nose. The nose should be left open for decrease in the concentration of oxygen. ventilation. Ventilation can be resumed as soon  Difficulty in feeding and suction procedures. as the tube has been placed.  Carbon dioxide build up can occur.  Once the tube is inserted the desired distance, attach a syringe and gently remove the gastric Sterilization: Autoclaving contents.  Remove the syringe from the tube and leave INFANT FEEDING TUBE (FIG.1.8) the end of the tube open to provide a vent for air entering the stomach.  A large tube may cause difficulty in making a seal. A smaller tube can be occluded by secretions. Uses  Feeding  Gavage feeding in infants < 34 weeks of gestation  Feeding of child with respiratory distress, bulbar palsy, polio, unconscious child and palatopharyngeal insufficiency Fig. 1.8: Infant feeding tube  Forced feeding in protein energy mal- (For color version, see Plate 2) nutrition  It has closed distal end with two lateral eyes  Aspiration and soft and rounded tip to prevent trauma  Gastric aspirate for shake test, acid-fast during application. bacilli, macrophages, polymorphs, fungus,  Length is 52 cm and is marked at 25 cm from poisoning. the tip for accurate placement.  To decompress stomach in intestinal obs-  Radiopaque line is provided throughout the truction length for X-ray visualization.  In unconscious child  Proximal end is fitted with mount for easy  Bag and mask ventilation (prolonged) to avoid connection to feeding funnel or syringe. gastric distention  Color coding is done for size identification.  Injecting drugs per rectal, enema  Gastric lavage HOW TO INSERT  Catheterization  Always measure the length of the tube. The  Umbilical catheterization for ABG, blood length of the inserted tube should be equal to sampling, exchange transfusion 10 Section I: Basics of Practical Pediatrics  Detect congenital anomalies:  Tube with radiopaque line, marked at every cm  Choanal atresia from 5 to 25 cm from the open distal tip for  Anal atresia accurate placement:  Tracheo-esophageal fistula  1st marking: Under surface of liver  Meatal Stenosis:  2nd marking: Hepatic vein  Infant (inability to insert FG 5)  3rd marking: Inferior venae cava  4 years (inability to insert FG 8)  Open distal end without lateral eyes eliminates  10 years (inability to insert FG 10) the chance of clot formation in the blind spaces SUCTION CATHETER (FIGS 1.9A AND B)  Atraumatic, soft and rounded open tip with two lateral eyes  For removal of secretion from oropharynx and trachea  Length: 52 cm. Fig. 1.10: Umbilical catheter (For color version, see Plate 3)  Has female flexible mount and luer lock A  Color coded funnel end connector for easy identification of size  Length : 40 cm  Sizes available : FG 4, 5, 6, 8  Optimal length for umbilical vein catheteri- zation: 20 percent of crown heel length or 50 percent of shoulder umbilicus length. B Uses Figs 1.9A and B: Suction catheter (For color version, see Plate 2) Can be used with venous or arterial routes for  Infusion UMBILICAL CATHETER (FIG. 1.10)  Transfusion  Administration of medication  Designed for intermittent or continual access  Blood sampling to the umbilical artery or vein of the newly born or premature baby  CVP monitoring.  Chapter 1: Instruments 11 COMPLICATIONS TONGUE DEPRESSOR (FIG. 1.12) Uses Immediate  Bleeding  To see the gag reflex  Thromboembolism  To examine the pharynx, oral cavity and  Infection. tonsils  To examine the movements of the palate and Late the uvula  Portal hypertension (extrahepatic)  Spatula test – To test for the spasm of the DILEYS MUCUS EXTRACTOR (FIG. 1.11) masseter muscle in a suspected tetanus case by trying to insert the tongue depressor in  It has atraumatic, soft and rounded, open tip between the teeth. with two lateral eyes and clear transparent container permiting visual examination of aspirate.  Spare screw top lid is provided to seal the container for safe transportation of specimen to the laboratory or aseptic disposal of container  Suction tube lengths available: 40 cm, 50 cm  Capacity: 25 ml.  Pressure: 100 mm Hg. Fig. 1.12: Tongue depressor (For color version, see Plate 3) TUBERCULIN SYRINGE (FIG. 1.13) It is a 1 cc syringe with a white piston (plastic syringes) or metal piston (glass syringes). Fig. 1.11: Dileys mucus extractor (For color version, see Plate 3) Uses  Obtaining mucus specimen for microbiolo- gical examination  Aspiration of secretion from oropharynx of newborn babies to ensure free respiration. Fig. 1.13: Tuberculin syringe (For color version, see Plate 3) 12 Section I: Basics of Practical Pediatrics Uses METERED DOSE INHALER  To administer PPD for Mantoux test  Most commonly used device  To administer BCG vaccine  Cannister with drug (1%), surfactant, preser-  To administer test doses of drugs such as vatives and propellent (80%) (CFC/HFA) Penicillin  Metered dose chamber (finite volume released)  Provocative testing – To test for allergens  A metering valve that dispenses a constant in bronchial asthma, atopy volume of a solution or suspension of the drug  Insulin injection in diabetes mellitus. (1cc is in the propellant. graduated to 40, 80 or 100 units)  Giving small doses of drugs e.g. Digoxin. DRUGS DELIVERED THROUGH MDI INHALERS (FIGS 1.14A AND B)  2 agonist  Ipratropium bromide  Inhaled steroids—beclamethasone, budesonide, fluticasone  Mast cell stabilizers—cromolyn sodium, nedocromolyn. Uses  Bronchial asthma (acute episode and sym- ptomatic asthma)  Hyperkalemia A SIDE EFFECTS  Tremors  Oral thrush  Ankle edema  Tachycardia  Hypokalemia. ADVANTAGES  Portable  Quick delivery  Precise and constant dose B  Light, compact, resistant to moisture Figs 1.14A and B: Metered dose inhaler  No drug preparation (For color version of Figure 1.14A, see Plate 3)  No contamination of contents.  Chapter 1: Instruments 13 DISADVANTAGES  Press canister and encourage the child to take tidal breathing with mouth open (if possible)  Needs hand breath coordination 5-10 times  Cold Freon effect (inability to breath when  Remove baby mask and wait for 30-60 seconds propellent is released in mouth) before repeating above steps.  Contains CFC WHY YOU MUST SHAKE MDI  Used with spacer (increases cost)  Time consuming to teach You must shake MDI before each actuation to give  Oropharyngeal deposition correct mix of propellent and medication as one is heavier than the other. How to Use Metered Dose Inhaler FLOAT TEST (FIG. 1.15)  Remove cap and shake inhaler in vertical direction  Breathe out gently  Put mouthpiece in mouth and at start of inspiration which should be slow and deep, press canister down and continue to inhale deeply  Hold breath for seconds or as long as possible then breathe out slowly  Wait for few seconds before repeating above steps. How to Use Metered Dose Inhaler Fig. 1.15: Float test with Spacer Device HOW TO PRIME MDIS  Remove cap, shake inhaler and insert into spacer device  If a new inhaler OR if you have not used the  Place mouthpiece of spacer in mouth MDI for one week spray two doses into the air  Start breathing in and out gently and observe before use to mix properly and check it working. movements of valve  Once breathing pattern is established press Aerosol Delivery Systems canister and continue to breath 5-10 times (tidal  MDI: Metered dose inhalers breathing)  DPI: Dry powder inhalers  Remove the device from mouth and wait for  Nebulizers 3 minutes before repeating above steps Selection of Device How to Use MDI + Spacer + Baby Mask  < 3 years : Metered dose inhaler + Spacer  Attach baby mask to the mouth end of spacer + mask  Shake MDI and insert it in the MDI end of spacer  3-6 years : Metered dose inhaler +Spacer device  > 6 years : Metered dose inhaler + Spacer  Cover baby’s mouth and nose with baby mask OR Dry powder inhaler 14 Section I: Basics of Practical Pediatrics PARTICLE SIZE  Requires hand breath co ordination  Delivery of medicines independent of external MMAD :Mass median aerodynamic factors diameter  Time consuming to teach MMAD 5μm :Deposited in oropharynx DPI DRY POWDER INHALER (DPI) (FIG. 1.16)  No CFC  Aerosol velocity depends on inspiratory flow  Rotahaler is used in children above 4-5 years rate of age  No hand breath coordination needed  Contains mouthpiece and reservior  Delivery of medication largely dependent on  Drugs administered: Salbutamol, Beclo- external factors methasone, Budesonide, Fluticasone, Sodium  Easy to teach cromoglycate  Requires high inspiratory flow >28 L/min.  They have the advantage of being portable and eliminate the need to co-ordinate actuation with NEBULIZER CHAMBER (FIG. 1.17) breathing environmental friendly, as they do not contain CFC  Nebulizers are used for delivering nebulized  There may be a problem in high humidity -agonist in acute severe asthma. environment (agglutination of particles), and high oropharyngeal deposition of drugs.  Dose of salbutamol used in nebulizers is 0.15 mg/kg/dose at 0, 20 min and 40 min and then depending on the response of patient 2 hourly or 4 hourly. Fig. 1.16: Dry powder inhaler (DPI) (For color version, see Plate 3) Comparison between Metered Dose Inhaler and Dry Powder Inhaler MDI Fig. 1.17: Nebulizer chamber  Contains CFC (For color version, see Plate 4)  High velocity aerosols  Chapter 1: Instruments 15 STEPS TO USE NEBULIZER  With/without valve  Polyamide/polycarbonate. 1. Calculate the dose of medicine (0.15 mg/kg/ Home made: water bottle dose; minimum dose: 1.25 mg) 2. Add saline to make a fill volume of 3-5 ml. Usually of 140–750 mL capacity. Incorporates one 3. Switch on the compressor and give aerosol for way valve that permits aerosol to be drawn from 8-10 minutes. chamber during inhalation only, diverting exhaled 4. As many patients are hypoxic, oxygen from gas to atmosphere & not disturbing remaining central supply or a oxygen cylinder should be aerosol suspended in the chamber. Combines the given, at a flow rate of 6-8 L/minute in place of benefits of spacer with advantage of protecting the compressed air. patient from loss of dose due to poor hand breath 5. Nebulization is given over 8-10 minutes, till you coordination. hear a spluttering sound. Can we combine two drugs:  Avoid combining steroids with other medications  Can combine salbutamol and ipratropium What is the optimal total volume:  3-5 ml What should be time for nebulization:  8-10 minutes. The following measures can improve the amount of drug delivered to the lung by nebulizer. Fig. 1.18: Volume spacer  The total fill volume should be about 3-5 mL (For color version, see Plate 4)  Tapping the sides ADVANTAGES  The optimal flow rate is 6-12 L/min, 30-50% of aerosol are in the respirable range of 1-5 μm  No need to actuate with inspiration  Slow deep inhalations and breath holding can  Increased drug deposition in lungs improve delivery:  Less deposition in mouth Drug Delivery  Eliminates Cold Freon effect: (inability to breath Device Drug delivery when propellent is released in mouth)  MDI + Spacer 10-15 %  Decreased chance of oral thrush  MDI 5-10 %  As effective as nebulizer.  DPI 5-10 %  Nebulizer 1-5 % DISADVANTAGES  Initiation can be more complex SPACER (FIG. 1.18)  More expensive than MDI alone  Holding chamber/resevoir types:  Less portable than MDI alone  Can reduce dose if not correctly given.  Small volume/large volume 16 Section I: Basics of Practical Pediatrics BONE MARROW ASPIRATION NEEDLE Therapeutic (FIG. 1.19)  Bone marrow transplantation CONTRAINDICATIONS  Coagulation disorders like hemophilia  Infection at biopsy area. COMPLICATIONS  Infection  Bleeding  Cardiac injury (if deep penetration occurs in sternal aspiration). Fig. 1.19: Bone marrow aspiration needle (For color version, see plate 4) BONE TREPHINE BIOPSY (FIG. 1.20) PARTS The Jamshidi needle is the most popular needle for  Stillete this procedure. The needle is tapered at the distal end to help retain the specimen. Currently,  Thick body with nail disposable needles are used.  Guard 2 cm from the tip (guard prevents through and through penetration of the bone). USES Bone marrow aspiration. SITE 1. Posterior iliac crest (both aspiration and biopsy) 2. Sternum (aspiration only in adults) 3. Anterior iliac crest (both aspiration and biopsy). Indications Diagnostic Fig. 1.20: Bone trephine biopsy (For color version, see Plate 4)  Idiopathic thrombocytopenic purpura  Aplastic anemia Indications  Leukemia  Megaloblastic anemia  Macrocytic anemias in which blood changes  Storage disorders, e.g. Gaucher’s disease are minimal  Infection, e.g. kala azar  Microcytic hypochromic anemias to help  Pyrexia of unknown origin distinguish iron deficiency from anemia of  Myelofibrosis. chronic disease and sideroblastic anemia  Chapter 1: Instruments 17  Normocytic normochromic anemia to detect VIM-SILVERMAN’S NEEDLE (FIG. 1.22) degree of ineffective erythropoiesis, pure red cell aplasia or aplastic anemia  Myelofibrosis (dry tap)  Evaluation of a “dry tap” aspirate  Acute leukemias  Lipid storage diseases Fig. 1.22: Vim-Silverman’s needle PARTS LUMBAR PUNCTURE NEEDLE (FIG. 1.21)  Trocar It is 10-12 cm in length and stilette of the needle  Cannula has pin which fits into the slot of the head of the  Bifid needle. needle. Spinal needle provides exceptional control when penetrating the dura mater. ADVANTAGES Large tissue is obtained and failure rate is low. DISADVANTAGES Complications are more compared to trucut needle. TRUCUT BIOPSY NEEDLE (FIG. 1.23) Fig. 1.21: Lumbar puncture needle Uses  Lumbar puncture  Cisternal puncture  Carotid angiography  Splenoportogram  For tapping fluids from the cavity, e.g. ascites or pleural fluids Fig. 1.23: Trucut biopsy needle (For color version, see Plate 4) Note  In children, ordinary needle is often used for Uses of Biopsy Needle lumbar puncture.  Liver biopsy  The advantage with the lumbar puncture needle  Kidney biopsy is that the stilette helps to keep the lumen of the needle patent.  Lung biopsy – rarely 18 Section I: Basics of Practical Pediatrics INDICATIONS OF LIVER BIOPSY  Absence of serologic evidence of streptococcal infection; normal levels of C3. Neonate  Mixed picture of AGN and nephrotic syndrome  Neonatal hepatitis  Severe anemia, very high levels of blood urea  Biliary atresia or anuria requiring dialysis.  Delayed resolution.  Galactosemia.  Oliguria, hypertension and/or azotemia Children persisting past 2 weeks.  Gross hematuria persisting past 3-4 weeks.  Chronic hepatitis  Low C3 levels beyond 6-8 weeks.  Cirrhosis  Persistent hematuria or proteinuria beyond  Metabolic: Wilson’s disease, Tyrosinosis, 6 to 12 months. Hemochromatosis  Malignancy Staging: Wilms’ tumor, Hodgkin’s lymphoma, Neuroblastoma THREE WAY (FIG. 1.24)  Diagnosis of malignancy: Hepatoma, hepato- blastoma. INDICATIONS FOR KIDNEY BIOPSY IN NEPHROTIC SYNDROME At Onset  Age 8 years  Persistent microscopic or gross hematuria, low serum C3  Sustained hypertension (>3 weeks) Fig. 1.24: Three way (For color version, see Plate 4)  Suspected secondary causes of nephrotic syndrome.  Three way is a T-shaped instrument with two inlets and one outlet. By a screw, either of the After Initial Treatment inlets can be connected to the outlet.  Proteinuria persisting despite 4 weeks of daily  Transparent polycarbonate main body facilitates corticosteroid therapy observation of flow. Arrow on the handle  Before starting treatment with cyclosporine A indicates the direction of flow.  Frequently relapsing or steroid dependant  Minimum priming volume required for accurate nephrotic syndrome (discretion of the pediatric drug administration. nephrologist). Uses INDICATION FOR KIDNEY BIOPSY IN  It is commonly connected to an intravenous ACUTE GLOMERULONEPHRITIS set where through one inlet IV fluids pass and through the other inlet, medications can  Systemic features: Fever, rash, joint pain, heart be given or CVP can be monitored. disease.  Chapter 1: Instruments 19  Aspirating fluid from the body cavities, e.g. Uses pleural tap. Through one inlet fluid is with- drawn from the body cavity and by changing  Intravenous fluid administration the direction of the screw the fluid from the  Drug administration syringe is pushed into the kidney tray.  Parental nutrition  Exchange transfusion  Total parental nutrition BLOOD SET (FIG. 1.26)  Dialysis MICRODRIP SET (FIG. 1.25) Fig. 1.26: Blood set (For color version, see Plate 5) This is similar to intravenous set except that there Fig. 1.25: Microdrip set (For color version, see Plate 5) is a filter in Murphy’s chamber that filters out clots. Hence, it is useful when blood has to be transfused.  Clear, soft, cylindrical and calibrated measured volume chamber with bold graduation. GUEDEL AIRWAY (FIG. 1.27)  Chamber injection port allows medication to be injected into burette chamber for medication mixture.  Chamber vent allows air to enter chamber through hydrophobic membrane to prevent solution contamination.  Burette sizes available: 110 ml, 150 ml.  1 ml of it contains 64 drops.  It contains Murphy chamber through which it is possible to regulate the number of drops falling per minute. A fluid level must be main- tained in the Murphy’s chamber. If the chamber gets full, it has to be reset.  If you want to give 40 ml/hr fluid through microdrip set, adjust it to set at just 40 drops/ Fig. 1.27: Guedel airway min. (For color version, see Plate 5) 20 Section I: Basics of Practical Pediatrics  Suitable for maintaining an unobstructed SPHYGMOMANOMETER (BP APPARATUS) oropharyngeal airway during general anesthesia and in unconscious patients. It has rounded Various phases are: atraumatic edges with smooth airway path for  Phase I : First appearance of clear, tapping easy cleaning sound. It represents the systolic  Length of Guedel airway used is 2/3rd of blood pressure distance between angle of mouth and temporo-  Phase II : Tapping sounds are replaced by soft mandibular joint. murmurs  Phase III : Murmurs become louder Uses  Phase IV : Muffling of sounds  Macroglossia  Phase V : Disappearance of sounds  Retrognathia Diastolic pressure closely corresponds to  Choanal atresia phase V. However, in aortic regurgitation, the  Neonatal resuscitation disappearance point is extremely low, sometimes 0  Seizuring child mm Hg and so phase IV is taken as diastolic BP in adults as well as children.  Unconscious child  Pierre Robin syndrome Uses INTRAVENOUS CANNULA (FIG. 1.28)  To measure the blood pressure (principal use of the instrument)  Hess’ capillary fragility test  Latent tetany – When the pressure is raised above the systolic BP for 2-3 minutes, typical carpal spasm appears and is known as Trousseau’s sign  To assess the respiratory reserve – Blow the mercury column (by placing the mouth to the inlet tube) upto 40-50 mm of Hg and try to hold it at this level  Diagnosis from recording of BP of lower Fig. 1.28: Intravenous cannula limb: Lower limb systolic BP > upper limb (For color version, see Plate 5) systolic BP and if crosses 20 mm of Hg, it  Contains transparent flash back chamber for is known as Hill’s sign, which is diagnostic easy visualization of blood to confirm veni- of Aortic regurgitation. Again, Lower limb puncture. BP < upper limb BP occurs in coarctation of aorta Uses  To draw venous blood  Venipuncture  To draw blood during blood donation  Chapter 1: Instruments 21 PULSES CONFIRMED CORD CLAMP (FIG. 1.30) BY SPHYGMOMANOMETER Pulsus paradoxus: Systolic BP is always more in expiration than in inspiration by > 10 mm of Hg. Water-hammer pulse: Pulse pressure is usually greater than at least 50 mm of Hg. Pulsus alternans: When the strong beats are heard during measurement of systolic BP (initial part of measurement), the pulse rate remains half of the actual rate (as weak beats do not reach the radial artery). With gradual lowering of the mercury column, the weak beats are also heard and thus, Fig. 1.30: Cord clamp (For color version, see Plate 5) the pulse rate doubles, i.e. returns to the actual  Provided with finger grip for safe and con- pulse rate. venient handling  Security lock to prevent accidental opening after CONDOM CATHETER (FIG. 1.29) clamping  Grooved clamping area to prevent slipping of umbilical cord. Uses  Clamping the umbilical cord of newborn baby immediately after the birth RESPIRATORY EXERCISER (FIG. 1.31) Fig. 1.29: Condom catheter (For color version, see Plate 5)  It has penile sheath/External catheter  Male catheter is specially designed for urine incontinence for day and night use in male patient  Proximal end is designed for easy connection to urine bag, making it simple to use  Provided with self-adhesive coated strip for Fig. 1.31: Respiratory exerciser proper fixing on to the penis (For color version, see Plate 6) 22 Section I: Basics of Practical Pediatrics  It consists of three balls Uses  It helps the patient to recover normal respiration after a chest or abdominal surgery Recording length/height of baby. URINE COLLECTION BAG (FIG. 1.32) SAHLI’S HEMOGLOBINOMETER (FIG. 1.34) INSTRUMENT i. Comparator: It contains Sahli tube. Com- parator has brown tinted glass pieces on either side for color matching an opaque white glass is present at back to provide proper illumination. ii. Sahli tube: Calibrated in gram% hemoglobin (2 to 24) on one side and in percentage (20 to 140) on other side. 100 percent being equivalent to Hb 17.3 g/dl blood. iii. Sahli pipette Graduated to.02 ml (20 mm3) Fig. 1.32: Urine collecting bag (For color version, see Plate 6) mark with rubber tubing and mouthpiece. iv. Glass rod stirrer  Bag graduated in ml to measure urine output  Contains non-return valve Uses  Conical inlet connector with cap Measurement of hemoglobin. INFANTOMETER (FIG. 1.33) Principle Blood is diluted in an acid solution, to form acid hematin. The brown color so developed is matched against standard brown tinted glass in the comparator and reading is taken in gram percent. PROCEDURE  Fill the Sahli tube to the 20 mark (3 g%) with N/10 HCl Fig. 1.33: Infantometer (For color version, see Plate 6)  Draw blood to the 0.02 ml mark of Sahli pipette It has a broad acrylic base with one sliding side  Wipe out any blood stick to the pipette from as per length of baby with dual scale for direct outside with cotton reading in cm from 0 to 45 and 45 to 90 cm. It has  Blow the blood from pipette into Sahli tube folding sides for easy storage. containing N/10 HCl  Chapter 1: Instruments 23 Fig. 1.34: Sahli’s hemoglobinometer 24 Section I: Basics of Practical Pediatrics  Mix the content quickly by gently shaking the PROCEDURE tube  Keep the Sahli tube back into comparator for  Fill the Wintrobe tube from oxalate blood with 10 min pipette up to zero mark.  Acid reacts with hemoglobin and converts it  Keep the Wintrobe tube in Wintrobe stand in a into acid hematin (brown color) vertical position for 1 hr and take the reading.  Compare it with color of standard com parator  Express the reading in mm 1st hour. Normal ESR value: 1 to 10 mm in 1st hour.  If the color of blood is darker than that of standard continue to dilute by adding distilled PCV (HEMATOCRIT) water drop by drop and stir it after adding each drop of distilled water till the color of solution  Fill the Wintrobe tube with EDTA blood. matches with standard.  Centrifuge the tube for 20 min at 2500 rpm.  Note the reading in gram percent. It gives Take the reading in percent. reading with error of 10%.  Centrifuge the tube again for 5 min and note the reading. OTHER METHODS FOR MEASUREMENT OF HEMOGLOBIN  Final reading is recorded when 3 consecutive readings are identical.  Cyanmethemoglobin method—Best method  After centrifugation blood is separated into  Alkaline haematin method 3 layers, tall bottom layer of packed red cells, thin middle layer of WBCs and platelets and top  Oxyhemoglobin method layer of clear plasma.  Carboxyhemoglobin method  Percentage of height of red cell volume is  Copper sulfate specific gravity method. hematocrit (PCV). WINTROBE’S TUBE WESTERGREN TUBE The recommended Westergren sedimentation tube INSTRUMENT is made from either glass or plastic, has a length of  Length 11 cm, diameter 2.5 cm about 30 cm and a bore of 2.5 mm.  It is open at top end and closed distally PROCEDURE It is calibrated from 0 to 10 cm, from above downward (for ESR) on one side and 10 to 0 cm  Draw the EDTA sample into clean dry from above downward (for PCV) on another side Westergren tube. of tube.  Adjust the rack so that the tube rests in an exactly vertical position. Principle of ESR  Leave undisturbed for 60 min. Differences in specific gravity between red cells  At the end of the hour read the height of and plasma leads to sedimentation resulting in clear plasma above the upper margin of the red cells to form roulex, which are aggregates column of sedimenting cells to the nearest of large volume but have small surface area. millimetre.  Chapter 1: Instruments 25  A poor delineation of the upper layer of red cells, RBC PIPETTE (FIG. 1.37) so-called ‘stratified’ sedimentation, has been attributed to the presence of many reticulo- INSTRUMENT cytes.  Report this measurement as the ESR (Wester-  Glass stem has 3 marking 0.5,1 and 101 gren) in units of mm in 1 hour. (volume) NEUBAUER’S CHAMBER  Glass capillary tube opens into wide bulb containing red glass bead See Figures 1.35 and 1.36.  Red bead helps in mixing the contents of bulb. USES Total RBC count. Fig. 1.35: Neubauer’s chamber Fig. 1.37: RBC and WBC pipette PROCEDURE  Fill the RBC pipette exactly upto 0.5 mark with blood  Now fill RBC diluting fluid (formal citrate solution) up to mark 101 (dilution 1 in 200)  Mix the content thoroughly for 2 minutes. Discard first 2-3 drops of diluted blood  Adjust the chamber and put coverslip in such a manner that both the ruled platforms are evenly covered by it Fig. 1.36: Method of counting cells  Now charge the chamber (improved Neubauer in Neubauer chamber chamber) 26 Section I: Basics of Practical Pediatrics  Wait for 2 min for settling of cells and then reference curves are based on extensive cross count sectional data of well nourished healthy  In erythrocyte count central double-ruled square children, assembled by the National Centre for is used. Red cells lying in 80 very small squares Health Statistics which are considered the best have to be counted. available for international use.  50th percentile of NCHS weight for age chart No of RBC/mm3 of Blood normally corresponds to the reference median. Number of cells counted in 5 squares (4 from It gives the value of the 50th child of a group corner and 1 from central) × 10,000. of 100 when they are arranged in ascending or descending order and where equal number of WBC PIPETTE (FIG. 1.37) children will have measurements smaller or larger than the 50th value.  Glass stem has 3 marking 0.5,1 and 11 (volume)  When we say 3rd perc