Infection in Returned Traveller Incubation Periods

Pediatric conditions synopsis

Condition Diagnostic criteria Management/comments Adrenal crisis Glucocorticoid deficiency: weakness, Hydrocortisone 2mg/kg or IV anorexia, nausea, vomiting, dexamethasone 0.1mg/kg hypoglycemia, hypotension, shock 5ml/kg of 10%D or 2ml/kg of 25% D Mineralocorticoid: dehydration, Treat other electrolyte abnormalities hyperkalemia, hyponatremia, acidosis and prerenal failure Afebrile seizures Seizures in absence of fever, supportive Midazolam 0.15mg/kg IV/IM 0.5mg/kg care for 5-10 minutes suggested. Escalate buccal if ongoing symptoms. Always check BSL Diazepam 0.2mg/kg IV or 0.4mg PR (both regularly. 10mg maxm) Phenytoin/Phenobarbitone 20mg/kg IV Anaphylaxis Multi-system allergic reaction → at least Serum tryptase only in unclear cases. Short one resp/cardio feature + at least one ½ life so if not + does not rule out diagnosis GIT/skin feature. Most common cause – O2, IM adrenaline 0.01ml/kg of 1:1000 foods, bites/stings, medications, others – (max 0.5ml in lateral thigh) repeat in 5mins exercise, idiopathic, latex if required. 6-12yrs 0.3ml, <6yrs – 0.15ml. Resp – RD, URT signs, tongue swelling, nebulized adrenaline only adjunct for URT stridor, hoarse voice, tightness in throat. obstruction. Adrenaline infusion 0.05-1 LRT signs – cough, wheeze, chest µg/kg/min. bolus fluids 20ml/kg. other tightness. therapies – steroids/ anti-histamine second Cardio – hypotension, LOC, pale/ floppy line after consultation. Neb salbutamol if infant. GIT – vomiting/ diarrhea, abdo wheeze+, newer anti-H: as not sedative pain. Skin – urticaria/ erythema, Admission 6-12h, overnight. OP f/u with angioedema, pruritus immunologist after 6 weeks as skin tests will return false +. Alert in ED system. Anaphylaxis action plan, Epipen dispense and train. 150µg <20kg, 300µg> 20kg. medicalert bracelet. Bronchiolitis Etiology: RSV, parainfluenza, adenovirus Mild: manage at home. Moderate: O2 Cough, tachypnea, hyperinflation, inhalation, frequent feeds. IVF if widespread crepitations dehydrated. Mild: alert, pink, feeding well, SaO2 >90% Severe: CPAP or ventilation Moderate: poor feeding, lethargy, marked resp distress, SaO2<90% Severe: above + signs of tiring, ↑PCO2 Cellulitis GABHS and S. aureus common cause. Flucloxacillin 25mg/kg PO/IV q6h Chickenpox Varicella zoster virus, 10-21days Exclude school until all lesions crusted or 1 incubation period. Short prodrome week after rash appearance. Zoster IG for followed by crops of small papular rash exposed children with risk of severe becoming vesicular and crusty in 10 days. disease. Supportive management. Upper half of body more commonly Croup Barking cough, inspiratory stridor and Steroids reduce LOS. hoarseness of voice. Commonly Mild: prednisolone 1-1.5mg/kg X2 or parainfluenza virus. Mild/ moderate/ dexamethasone 0.15mg one dose. severe depending on Severe: 0.6mg/kg IM/IV dexamethasone. RR/SaO2/effort/stridor at rest Adrenaline 5ml 1:1000 nebs. >1 dose inform ICU Gastroenteritis Assessment – correct ∆, Rehydration flowchart – oral, rapid oral, comorbidities/risk factors, blood testing, NGT, IV therapy – degree of dehydration resuscitation/replacement/ maintenance, Indications for EUC – severe dehydration, EUC monitoring comorbidities, altered LOC, doughy skin, Early re-feeding, discharge criteria, parent home therapy with hypertonic / information. hypotonic fluids, prolonged or profuse illness. Henoch-Schönlein Triad: pupuric rash (mainly lower) on Document BP rarely can develop CRF. purpura limbs and buttocks, joint pain/ swelling Consider prednisolone 1mg/kg x 2weeks and abdominal pain. 2-8yrs. h/o recent URTI. Hematuria >90%. Subcutaneous edema. Hip: transient Commonest cause for limp in pre-school Diagnosis of exclusion – supportive synovitis years, 3-8yrs, recent URTI, well child, treatment mild-moderate ↓ range of motion Hip: Perthes Avascular necrosis of capital femoral Bone scans – immobilisations, spica and disease epiphyses, 2-12yrs (4-8 common), 20% orthopedic consult bilateral, ice-cream cone on x-ray. Limp, pain with restricted hip motion Hip: Slipped capital Late childhood/ early adolescence, wt Need frog lateral views in all. May need femoral epiphyses >90th percentile, externally rotated surgical fixation bilaterally prophylactically. shortened, decreased hip movement, esp int.rotation. may be bilateral. Hypernatremia Moderate 150-169 , severe - >169 Rapid correction risk of cerebral edema. mmol/l. usually due to water loss excess Goal reduction of Na ≤ 12mmol/day. Initial of Na. diabetes insipidus and sodium gain resus with 0.9%NS then 0.45%NS or 0.9% from ingestion of high Na rehydration for NS + 5%D. fluid deficit corrected over 2- fluid loss 3days. Hypertension Secondary HT in children 75% renal SL/PO nifedipine 0.5-1.0mg/kg/dose BD. causes – PSGN,CGN, obstructive Labetalol IV 0.2mg/kg q10min. hydralazine uropathy, reflux, reno-vascular, HUS, 0.2mg/kg PKD. 15% cardiac – coarctation, endocrine 5% - phaeo. Hyperthyroidism, adrenal hyperplasia, cushing’s. others 5% - CNS lesions, steroid therapy. Hypoglycemia Moderate <2.6mmol/L. severe Oral feeds, 2ml/kg of 10%D IV bolus <1.0mmol/L followed by infusion if ongoing. If poor response consider 0.02mg/kg IV/IM glucagon Hyponatremia Defined as <125mmol/L. commonly Confirm not pseudo ↓Na. correct urgently hypotonic fluid adm. SIADH d/t to 120-125 depending on severity of meningitis, encephalitis, pneumonia, symptoms. Using 3% NS as per Na deficit bronchiolitis, sepsis, surgery or pain. calculation. Once symptom control then Endocrine cause: adrenal hyperplasia, 0.5mmol/hr only. Addison’s or psychogenic polydipsia Immune Acute (90%) – post-viral settles by 2- FBC and film usually sufficient. Steroids may thrombocytopenic 6mths. Chronic (10%) >6mths. Bruising ↑platelet numbers quickly but no effect on purpura (ITP) and petechiae common. Bleeding mortality/ chronicity. Threshold <20x109/L complaints less common. ICH <1% very – tapering prednisone, HIG IV for severe rare. urgent cases, Splenectomy for chronic No abnormal findings – no cases. pallor/lymphadenopathy/HS megaly. r/o leukaemia Impetigo Bullous lesions with crusting and Topical muciprocin + above if treatment discharge. Highly contagious. GABHS and fails. Exclude from school until sores S. aureus common. disappear. Inhaled foreign Sudden event, coughing, choking ± Complete – open airway if FB seen take out body vomiting. CR arrest in case of complete with Magills, prone, backblows x 5, supine obstruction. Partial – coughing, chest thrust x5, lateral chest thrusts. PPV to wheezing, fever and dyspnea, persistent push FB further one side, surgical airway if pneumonia, assymetrical chest movt, above cords and unable to grasp with tracheal deviation or CXR findings forceps. Intussusception 2mths-2yrs. Peak 5-9mths. Intermittent Plain AXR – target/crescent sign, US – pain, crying, pallor, lethargy, vomiting, choice of investigation. Air enema – blood/ mucus/ red currant stools, diagnostic and therapeutic. Surgical reg. to diarrhea. Hypovolemia/shock. accompany patient. Jaundice – Pale stools/ dark urine, raised conjugated Treatment of cause, hydration, conjugated fraction >15%, all potentially serious phototherapy and exchange transfusion causes – biliary atresia, choledochal cyst, neonatal hepatitis, metabolic Jaundice – Commoner, sepsis, suspected hemolysis. Assess for unwell – sepsis, dehydration/wt. unconjugated Kramer’s rule level 1 – head and neck gain, onset after 48hrs – hemolysis, blunt 100µmol/L, level 2 – upper trunk 150, trauma – cephalhematoma, maternal blood level 3 – lower trunk thighs – 200, level 4 group, family history – G6PD, – arms and lower legs 250, level 5 – spherocytosis, plethora – polycythemia, palms soles >250 µmol/L. hepatosplenomegaly – hepatitis, metabolic. Kawasaki’s disease Fever > 5 days plus 4 of 5 of: DD – scarlet fever, SSS, TSS, measles, viral Polymorphous rash, bilateral exanthema, SJS, RA and drug reactions. conjunctival injection, mucous Treatment – IV immunoglobulin 2g/kg over membrane changes (lips, strawberry 10hrs for 10 days. Aspirin 3-5mg/kg daily x tongue, pharyngeal mucosa – red), 6-8weeks. peripheral changes – erythema (palms/soles), edema hand/feet, desquamation, cervical lymphadenopathy. ASOT/ anti-DNAaseB, 2D-echo(0,6-8 weeks), platelet↑ 2nd week. Elevated LFT. Meningitis Child>2months – S.pneum. N.men. Hib. >2months – cefotaxime 50mg/kg <2months – GABHS, E.coli and other +dexamethasone 0.15mg/kg q6h both. gram neg, Listeria m. + above. 4weeks-2months – above + ben pen Fluid mx, seizure mx, notification, 60mg/kg q4h + gent 5mg/kg. analgesia and family care. <4weeks above - dexamethasone Metabolic diseases Urea cycle defects – N or ↑ pH, N BSL, N Seizures, poor feeds, apnea, SIDS, ketones, ↑↑ammonia. metabolic acidosis/hypoglycemia/ketosis/ Organic acidemia - ↓pH, any BSL, N or ↑ ammonia/jaundice/ dehydration ketones, ↑ ammonia. Treat with consult – 10%D + intralipid Ketolysis defects (MSUD) – N or ↓pH, maintain + prot. balance and special ↑↑ketones, N ammonia. therapy. FA oxidation defects – N or ↓pH, no ketones, N or ↑ ammonia. Pituitary/adrenal def. – N pH, ↓BSL, ↑ketones, N ammonia. Nappy rash Dermatitis confined to area covered by Disposable nappies, frequent nappy nappy. changing, cleansing, barrier cream, nappy DD seborrheic dermatitis – non-itchy free time, nystatin cream if associated salmon pink flaky patches candida infection (satellite lesions), steroid face/limbs/trunk/ skin folds cream if associated inflammation. Atopic derm. Psoariasis – sharp non- scaly plaques intertriginous areas. Perianal strep. Cellulitis – 1-2cm around anus, fissuring, maceration, painful defecation. Zinc deficiency – sharp anogenital rash, peri-oral/nasal/acral dermatitis, alopecia, diarrhea and failure to thrive Threadworm, Malabsorption and histiocytosis Near drowning Poor prognostic factors pre-ED – Category A most recover >90%, Category C age<3yrs. Immersion time >10minutes, 10-23% survival but with permanent rectal temp <30˚, delayed and prolonged neurological impairment. resus. CPR till hospital, need for CPR, Additionally parameters at 24hrs have been pH<7.10 score <2 (90% survival), ≥3 (≈5% defined. survival) Neurological classification on arrival – A – awake, B – stuporous but arousable, C – comatose C.1 – decorticate, C.2 – decerebrate, C.3 - Flaccid Necrotizing fasciitis GABHS, S. aureus, anerobes Flucloxacillin 25mg/kg + clindamycin Severe systemic symptoms + tissue 10mg/kg 6hrly crepitus likely. 25% mortality Neonatal screening Done with heel prick by 48-72hrs looking test ofr PKU/CF/hypothyroidism/ MCAD + other metabolic diseases Orbital cellulitis Strep. Pyogenes, S.pneum. S.Aureus IV cefotaxime 50mg/kg q6h + IV >5yrs S.Aureus most likely. Hib unlikely flucloxacillin 50mg/kg q6h. LP c/I until CT d/t immunization performed. If Hib then rifampin prophylaxis Proptosis/ opthalmoplegia/ visual acuity for household contacts as with meningitis. changes → urgent CT, surgical drainage Perioribital Organisms as above. Meningitis can co- Mild – PO augmentin cellulitis exist. Decision for LP clinical. Moderate – flucloxacillin 50mg/kg q6h Severe as for orbital cellulitis Osteomyelitis Commonly lower limbs. Most commonly Flucloxacillin 50mg/kg q6h IV S.aureus. GABHS/Hib less common and + consider vancomycin 50mg/kg in high risk salmonella in sickle patients. Limp/non- cases weight bearing, localized pain +movt. Ortho referral early Tenderness, soft tissue redness/swelling, ± fever Septic arthritis Symptoms as above + ↓ROM joint, soft As above + urgent aspiration ± arthrotomy tissue swelling+ redness more common and washout than OM + fever. Same organisms as OM Otitis media - 2/3rd children one episode by age 3, 90% Complications (rare) – mastoiditis, acute by school entry. Peak 6-18months. Viral labyrinthitis, intracranial infection (25%), S.pneum (35%), H.inf all strains (abscess), facial nerve palsy, sinus (25%) and Moraxella C. (15%) thrombosis and benign ICH Loss of landmarks, light reflex, Antibiotics ↓ symptoms at 24hrs in 5% dull/opaque TM, TM colour change, cases. Reassurance and analgesia LA + PO. ↓TM mobility. URTI symptoms. Otorrhea r/v 48hrs by LMO → PO augmentin - pus 15mg/kg x 7d Otitis media – Persistence of symptoms beyond weeks Reassurance, role of antibiotics doubtful serous after episode of AOM. Recurrent → but recent study?? conductive hearing loss. Smoking exposure, dummy use. Language/literacy/cognitive effects Hearing loss f/u and grommet insertion??? unknown Persistent nasal Infection – viral, bacterial If recurrent consider – anatomical causes, discharge (SP,Hib,Moraxella), allergic (seasonal immunodeficiency, ciliary dysfunction, CF perennial), chemical, obstructive (adenoids, FB) Pertussis Bordetella pertussis. <6mths highest risk Admission age<6mths +unwell children. (whooping cough) of complications (apnoea, pneumonia, Macrolides reduce period of infectivity but encephalitis). Infectious prior to onset to does not alter course or cough length. 21days post onset if untreated. Cough Infectivity 5 days post therapy. persists for months. Prodrome + Clarithromycin 7.5mg/kg BD x7d. exclusion paroxysmal cough spell, whoop± from school 5d post-therapy, if coughing vomiting. 70-100% family contacts +. NPA >21d no need for therapy or exclusion. for immunofluorescence (choice), Contacts <12mths, pregnant women plus serology rarely affects mx adults with chronic illness consider treatment. Pneumonia Lobar consolidation – bacterial (SP, Severe cases → IV flucloxacillin 50mg/kg SA,Hib), subacute onset, prominent q6h + gent 7.5mg/kg cough ± headache ± sore throat – Mycoplasma → PO roxithromycin, Mycoplasma, coryzal symptoms, diffuse moderate cases → IV BP + Gent once crackles, minimal patchy xray changes - improved PO amoxicillin + roxithromycin viral Pulled elbow Age: 1-4yrs. 50% cases no h/o “pull” DD – Supination/flexion or pronation/flexion fracture/inflammation/ infection. X-ray if maneuver, expect distress, ‘click’ felt over diagnosis in doubt or failure to reduce. radial head. Review in ten minutes. Symptoms – not using limb, elbow in extension, forearm in pronation, minimal distress at rest. No swelling, deformity of elbow/wrist. Check shoulder/clavicle. Marked pain/ resistance to supination of forearm. Purpura – Virus (enterovirus/influenza, others), Well child + purpura >2mm consider dx/mx petechiae N.men., bacteremia (SP, Hib), HSP, ITP, for meningitis unless HSP. Well child leukemia. Petechiae in SVC distribution mechanical causes – consider short term d/t vomiting or coughing. stay or early f/u. well child no mechanical >90% not meningitis, most causes causes - investigate→ WCC/CRP + unidentified. Unwell child/ purpura observation. If partially treated with Abs >2mm size, abnormal WCC ±↑CRP consider observation or investigations. consider serious causes. Pyloric stenosis Usually 2-6weeks of age. Risk factors – Fluid resus. Maintenance fluids, NBM, NGT male, firstborn, Caucasian, parental if ongoing vomiting. Correct EUC history. Progressive forceful projectile abnormalities over 48hrs. K replacement. vomiting, non-bilious, 10% blood stained. Correct bicarbonate level. Ramstedt’s Hungry post episode. Weight loss. Gastric pyloromyotomy. Restenosis 1-2% peristalsis and pyloric mass. Hypochloremic hypokalemia metabolic acidosis. Ultrasound sensitive. Scrotal pathology See separate table below Seizures – afebrile ABC, duration, BSL, past history, Support ABC, O2, monitor, IV access, BSL, comorbidities – VP shunts, renal failure, EUC/CMP, venous gas, BDZ (repeat dose), endocrinopathies, focal features, fever, phenytoin or Phenobarbitone, pyridoxine, medications. Secondary causes - ↓BSL, thiopentone RSI. EUC abnormality, meningitis, overdose, Midazolam 0.15mg/kg IV/IM 0.5mg/kg PO, trauma, stroke/ICH Diazepam 0.2mg/kg IM, 0.4mg/kg PR, Phenytoin/Phenobarbitone – 20mg/kg IV, midazolam infusion – 1-5µg/kg/min Seizures – febrile 3% of healthy children, Brief <10m in Septic workup for <6mths age. Minimal febrile child >38˚ in child aged b/w 6mths clothing. Tepid sponging, baths and fan and 6yrs no past afebrile seizures, no ineffective. Paracetamol no evidence but progressive neurological condition or no symptomatic for underlying illness. signs of CNS infection. Risk of meningitis Parental information and advice key. 0.5-2% for <10m, 17% for >30m seizures. Treatment as above if seizure duration Recurrence during same illness 10-15%, >10min in ED. recurrence 50% age<1yr, 30% <2yr. risk factors for future seizure disorder – family history, neurodevelopmental issue, atypical seizure. No risk factor <1% 1 risk factor 2% risk, 2 risk factors 10% risk. Sickle cell disease Acute crises – infection, dehydration, O2, hydration for all ED presentations hypoxia, drugs (sedatives and LA) Look for signs of infection, check ED presentations – fever, vaso-occlusive immunization, prophylaxis, hydroxyurea crises, acute chest syndrome, acute use, cultures, CXR. splenic sequestration, aplastic crises, Flucloxacillin + gent. Analgesia – stroke, priapism paracetamol 20mg/kg, codeine 1mg/kg, ↑risk of encapsulated organism e.g. ibuprofen 10mg/kg, morphine pneumococcus. 0.05mg/kg/dose consider PCA if age appropriate. Consider transfusion. Long term care and education. Sinusitis – acute Usually follows viral, potential source for CT indicated for failed medical mx, bacterial orbital/PO cellulitis. Same organisms. complications or surgery mx. Sinus Nasal d/c, nasal obstruction, tootache, puncture for cultures (nasal d/c facial pain (unilateral), headache, fever, contaminated) inflamed nasal mucosa, pus from middle 1st amoxicillin 15mg/kg tds, 2nd augmentin meatus, maxillary transillumination + 15mg/kg 3rd or severe IV flucloxacillin + middle ear changes cefotaxime both 50mg/kg q6h Sore throat – >85% viral, 15-30% GAS. Controversy Viral → symptomatic Rx pharyngitis over Ab use where rheumatic fever EBV → symptomatic Rx, explain course, incidence low. avoid penicillin URTI symptoms → viral GAS → throat swab + PO penicillin phenoxy Fever/malaise/generalized l’pathy ± – 250-500mg BD or erythromycin 20mg/kg splenomegaly → EBV PO BD or IV/IM penicillin if unwell. f/u Fever, pharyngo-tonsillitis, tender culture results if negative cease Ab tonsillar lymph nodes → GAS Staphylococcal Blistering, exfoliative reaction due to Treatment same as cellulitis scalded skin toxins of S. aureus syndrome (SSSS) Stridor Harsh, barking cough + ↑temp → croup. See individual management guidelines Low pitched stridor + drooling, absent Lateral cervical x-rays do not aid diagnosis cough → epiglottitis. IV access deferred in acute setting Sudden onset, coughing, choking, Child to remain with parent and do not aphonia → FB aspiration. upset child Swelling of face/ tongue, wheeze/ rash → ETT size 0.5-1 less than usual (4+ age/4) anaphylaxis ↑↑fever, hyperextension of neck, dysphagia, pooling of secretions in throat → retropharyngeal/ peritonsillar abscess Toxic + markedly tender trachea → bacterial tracheitis Pre-existing stridor → congenital abN, floppy larynx, subglottic stenosis, laryngotracheomalacia Supraventricular Infants – pallor, dyspnea, poor feeding. Shocked child – O2, IV access, Diazepam IV tachycardia Older – palpitations, chest discomfort. 0.2mg/kg, synchronized DC 1J/kg. Regular tachy. Hypotension, CHF in Unsynchronized if polymorphic or VF. infants. ECG – narrow complex Consult early tachycardia. Consult if broad or irregular. Stable child – vagal maneuvers or Continuous ECG trace and BP monitoring adenosine Vagal – gag/icepack/iced water for infants max 30s. (do not use eyeball pressure), valsalva if old enough. IV adenosine → cubital fossa IVA + 3-way tap, 0.1mg/kg dilute in 1ml NS, 10ml NS flush. Check reversion ECG for concealed pre-excitation and other abN. If reverts consider 0.2mg/kg dose. Follow up plan for cardiology. Syncope Brief sudden LOC and muscle tone d/t History of event and bystander info cerebral ischemia or inadequate significant. Exertional vs. stress; ECG to look O2/glucose to brain. Lasts few seconds, for dysrhythmias, abnormal PR, ↑QT. if limp/unresponsive, minimal tonic-clonic unusual signs consider – further movements likely, back to normal on investigations – EEG/CT /2-D ECHO etc. awakening Vaso-vagal, orthostatic, cardiac → structural – AS, tetralogy, atrial myxoma, Arrhythmia - ↑QT, AVB, SSS. Resp. → cough, hyperventilation, breath holding. Metabolic → anemia, ↓BSL, hysteria. Urinary tract Definitive diagnosis by culture of urine in <6mths always admit IV Ab. Fluid resus for infection sterile fashion – MSU/SPA/ CSU. shocked child. Gent 7.5mg/kg IV/d + ben Symptoms non-specific, UTI does not rule pen 50mg/kg q 6h age>1mth. Mild cases – out other infections. 2% children have trimethoprim 4mg/kg BD or co-trimazole asymptomatic bacteruria. LP in any child 0.5ml/kg BD or cephalexin 15mg/kg TDS X 1 even if UTI + if symtpoms don’t match. week. Check Ab sens in 48hrs. all children Loin, abdo pain, frequency and dysuria. with 1st episode to have renal US prior to Any growth on SPA → + UTI, CSU >103 discharge (males) or as OP. MCUG decision CFU → + UTI, MSU >108 CFU or 105 CFU by Ped. f/u required with ped. pure growth → UTI +. Urticaria Pruritic, elevated skin lesions surrounded No investigations for acute. Chronic → FBC, by erythematous base → hives. Transient differential, ESR and ANA. extravasation of plasma into dermis. Remove identifiable cause, col compresses, Common 25% of all individuals. Deeper reassurance, anti-histamines – subcutaneous extension → angioedema promethazine 0.2-0.5mg/kg/dose q6-8h less common, involves face, hands, feet IV/PO/IM (C/I <2yrs), cetirizine sometimes other areas – trunk, genitalia 0.2mg/kg/dose q12h. severe cases single and MM. acute <6wks, chronic >6wks. PO prednisolone. Referral for Causes – medications, viruses/bacteria, chronic/severe/refractory cases or food, bites/stings, angioedema of airways. pressure/cold/exercise. If recurrent consider C1 esterase inhibitor def. DD – Erythema multiforme – rash not itchy, non-mobile rash, target lesions with central blister, purpura or ulcer. Pityriasis rosea, mastocytosis, vasculitis (HSP) Von Willebrand Most common inherited disorder Antifibrinolytics – tranexamic acid disease (VWD) affecting 0.1-1%. Deficiency of VWF → 25mg/kg/dose TDS X 5-7d. Age >5yrs + inadequate platelet adhesion and 2˚ successful DDAVP challenge for deficiency of factor VIII. Males=females. moderate/severe cases 0.3µg/kg in 50ml NS Easy bruising, bleeding from MM and IV over 3mins. VWF/factor VIII concentrate post-op bleeding. if no response to above + severe bleeding – Type I ↓VWF→ mild bleeding, type II dose as advised by blood abN VWF→ variable bleeding, type III bank/haematologist (25-60units/kg) (rare) absent VWF → moderate to severe bleeding. Vulval ulcers Rare but distressing d/t concerns re: STI. History, symtpoms, ass. Features, other Most not STI. Causes: Aphthous, lesions, ocular symptoms, family history. infections – HSV/EBV/CMV/VZV/GAS Viral swabs – HSV I and II (PCR/ culture), /mycoplasma/molluscum, autoimmune – gram stain and bact/fungal CS. Crohn’s, BehÇet’s, vasculitis, Serology – HSV/EBV/CMV/ mycoplasma pemphigus/pemphigoid. Drug reactions – CRP/ESR/ANA. If sexually active – add urine fixed, SJS/TEN. Other – lichen sclerosus, PCR for chlamydia/ gonorrhea pregnancy. folliculitis, allergic dermatitis. STI – HSV Serology for RPR/HIV. Definitive RX after most common, syphilis, rarely results. Local anesthetics, analgesics, LGV/chancroid. barrier creams, salt baths.

Acute scrotal pain Diagnosis Suggestive features on history Suggestive features on examination Torsion of the testis Sudden onset testicular pain and Discolouration of scrotum; swelling; occasionally nausea, exquisitely tender testis, riding high vomiting. Note: pain may be in the iliac fossa Torsion of the More gradual onset of testicular pain Focal tenderness at upper pole of appendix testis testis; "blue dot" sign – necrotic (hydatid of Morgagni) appendix seen through scrotal skin Note: Difficult to distinguish from testicular torsion Epididymoorchitis Onset may be insidious; fever, Red, tender, swollen hemiscrotum; vomiting, urinary symptoms; rare in tenderness most marked pre-pubertal boys, unless underlying posteriolateral to testis. Pyuria may genitourinary anomaly, when be present. associated with UTI. Incarcerated inguinal History of intermittent inguinoscrotal Firm, tender, irreducible, hernia bulge, with associated irritability inguinoscrotal swelling Idiopathic scrotal Swelling noted but child not distressed Bland violaceous oedema of oedema scrotum, extending into perineum + penis; testes not tender Hydrocele Swollen hemiscrotum in well, settled Soft, non-tender swelling adjacent to baby testis; transilluminates brightly. Henoch Schonlein Painful scrotal oedema, with purpuric may be difficult to distinguish from purpura rash over scrotum. May have testicular torsion in absence of other associated vasculitic rash of buttocks features and lower limbs, arthritis, abdominal pain with GI bleeding, and nephritis Testicular or Scrotal trauma eg. straddle injury, Tender swollen testis. Bruising, epididymis rupture bicycle handlebars, sports injury. oedema, haematoma, or Delayed onset of scrotal pain and haematocele may be present. swelling. Infection in returned traveller – incubation periods Infection Incubation period Malari P.falciparum 7 days (minimum) to 12 weeks (usual maximum) a Other Plasm.species. Weeks to several years Dengue 3 - 14 days Hepatitis A 14 - 50 days Hepatitis B 45 - 180 days Typhoid 3 days - 3 mths Campylobacter 1 - 10 days Shigella 12 hrs - 4 days Viral hemorrhagic fevers 2 - 21 days Influenza 2 - 5 days Dressing Choices

Dressing types Examples Advantages Disadvantages Indications Contraindications Semi- OpSite, Some moisture Exudate may Superficial Highly exudative permeable – Tegaderm evaporation, pool, may be wounds. As a wounds. thin, adhesive, Reduces pain. traumatic to secondary transparent Barrier to remove. dressing. polyurethrane external film contamination. Allows inspection. Non adherent Jelonet, Reduces Does not absorb Burns. Wounds Allergy Moist (Tulle Unitulle adhesion to exudate. healing by Gras Dressing) – Bactigras, wound.Moist Requires secondary Gauze Sofra-Tulle environment aids secondary intention impregnated healing. dressing May with paraffin or induce allergy or similar. May be delay healing impregnated when with antiseptics impregnated or antibiotics Non adherent Melolin, Low wound Not suitable in Wounds with Dry wounds (may Dry Thin Melolite, adherence. May high exudate moderate cause tissue perforated Tricose absorb light Can dry out and exudate dehydration) plastic film exudate. stick to wound. coating May require attached to secondary absorbent pad dressing Fixation Sheet Fixomull, Can be used Dressing needs Wounds with Infected wounds Porous Hypafix, directly on washing with mild exudate, allergy to polyester fabric Mefix wound site. soap and water not needing adhesives with adhesive Conforms to pat-dried twice frequent review backing body contours, daily. Requires good pain relief application of oil and controls prior to removal oedema, – ideally soaked Remains in oil and permeable wrapped in cling allowing exudate film overnight. to escape and be washed and dried off wound. Dressing changes can be left for 5-7 days. Calcium Kaltostat Forms gel on May require Moderately or Dry wounds or Alginate Natural wound and secondary highly exudative hard eschar polysaccharide hence moist dressing. Not wounds. Need from seaweed environment. recommended for haemostasis Reduces pain. in anaerobic Can pack cavities. infections. Gel Absorbent in can be confused exudative with slough or wounds. pus in wound. Promotes haemostasis. Low allergenic. Foam Dressings PolyMem Moist, highly Set size of foam Wounds with Dry wounds. Polyurethane absorbent and may be limited mild to Wounds that foam dressing protective by wound size moderate need frequent with adhesive exudate. review. layer incorporated Hydrocolloid Duoderm Retains moisture, Avoid on high Burns Dry wounds Dressings painless removal. exudate wounds (small)Abrasions Infection Polyurethane film coated with adhesive mass Paper adhesive Micropore Non allergenic. Non absorbent Small wounds Exudative or large tapes Adhesive Provides wound wounds. tape may be support applied directly to healing laceration

Decision Tree - Types of wounds and dressing options

Wound Type Dressing options Review times Dry necrotic wound Moisture retention eg hydrocolloid, semi 3-4 days permeable Slough – covered wounds Moisture retention and fluid absorption eg 3-4 days hydrocolloid, alginate Infected wound Avoid semi occlusive dressings. Consider 1-2 days alginate or hydrocolloid if high exudate Graze, abrasions – clean Film, tulle, fixation sheet or dry 2 days Graze, abrasions – soiled Dry or tulle 2 days Puncture wounds or bites Open or dry 2 days Laceration – sutured Open or dry, consider paper tape support 3-7days see Lacerations after suture removal Burn-minor Burns Film, medicated tulle, fixation sheet 4-5 days visual review leave dressing on if healing see Burn-major or requiring Plastic wrap prior to surgical review, Inpatient review admission eg special areas medicated tulle Burns Chronic wounds eg ulcers, PEG Hydrocolloid, alginate, foam 5 days sites etc