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Ok, can someone let me, I think? Yeah. Ok, perfect, great. So, thanks very much. Um So hi, everyone. Thanks so much for joining tonight. Um My name is Malvi. I'm a final. Yeah, a question about a very common pediatric um cardiology and respiratory conditions. So we're going through um congenital heart disease first and then moving on to very common respiratory presentations that you see um in ed and on the wards um all the time. Um So if you're new to teaching things, um thanks very much for coming and um a big welcome to you all. Um So we're a group of medical students who are passionate about teaching. Um We focus on core presentations and teaching you how to really reason through diagnoses um of conditions that you see very commonly um in clinical practice. Um We're all medical students um and we're all um obviously, we, we all really enjoy teaching, but all the slides are reviewed and checked by doctor doctors to make sure that they're accurate and that they reflect the latest guidance um given by. Um nice. And um if you like today's tutorial, please do follow us on our Instagram for um, further tutorials. We do them every Thursday evening at six PMU K time. Um And obviously if you look at our meal page, you, you can see a schedule of all our upcoming events. Um So today's tutorial, um I'll be actually starting off with congenital heart defect just because that's the more complicated topic and I want to spend a bit more time on it. Um So we're talking you through the key principles of how um I approach them and teaching you how to pick out key things in questions to point you towards the right answer. And then we'll move on to respiratory conditions, um particularly focusing on severity, classification and management of conditions, kind of varies depending on the severity of them. Um OK, so before we start about congenital heart disease, I just want to give a quick disclaimer that this is quite a confusing and difficult topic. Um And if you're in the UK and you're sitting there, um AK T MLA, this is likely to be about 2 to 3 questions in your um A KT. Um And I would pediatric topics before this as um they're obviously a little simpler and likely to come up um in greater quantities. Um So the M and A content map does suggest does um highlight congenital abnormalities, but it doesn't actually state any specific conditions. But the ones I've gone through today are the ones that I think are the ones that come up the most um and are the most common conditions as well. Um So just a bit of background before I move on to the main bulk of the presentation, which would be going through. Um SBA questions, I just want to draw your attention to the key differences between fetal and adult circulation. Um So obviously, as you know, um in the fetus, um we don't, the fetus doesn't need the lungs, it gets all of its oxygen and all of its nutrients from the mother via the placenta. Um So, to prevent blood, um unnecessarily passing to the lungs, there's actually a very high pulmonary vascular resistance. Um which means that blood, most blood kind of directly bypasses the lungs and goes um straight to the left side of the heart. Um So to facilitate this, there are two main connections between the right and the left side of the heart. So there's the foramen ovale, this is what is more kind of casually known as the hole in the heart and this is between the right and the left atrium. Um And the second thing is the ductus arteriosis. So this um if you have a look on, I'm not sure if you can see my cursor, I don't think you can. Um But on the diagram, just on the top, um just towards the right side, there's a label um pointing to the ducts arteriosis. And this is a connection between the pulmonary artery and the aorta. So any blood that does go into the right ventricle um and goes into the pulmonary artery. Um most of that will go across into the aorta and avoid passing into the lungs. So, obviously, at birth, um a lot of different things need to happen to change this very quickly. Um So the baby can adapt to actually breathing oxygen and coming out into the um into the world. So when the baby takes its first breath, the lungs expand and this means that the pulmonary vascular resistance drops very suddenly. And this means that blood then um starts flowing to the lungs. Um The greater um flow to the lungs means that there's more blood that then returns back to the left atrium. This means that the pressure in the left atrium increases and the fore I'm going to violate that hole in the heart, um that gets forced shut. And the third thing, the thing that's really, really important to appreciate is that the ductus arteriosis, that connection between the pulmonary artery and the aorta um closes. This isn't as quickly as the first two things it can take about um 12 to 24 hours and this happens due to um the removal of placental prostaglandin. Um This is important to know as sometimes in conditions where we want to artificially keep the duct open. We give babies um medicine. So we give them prostaglandin medicines um to help treat their congenital heart conditions. So, gonna move on now to just a quick note on risk factors for congenital heart disease. Um So these are some common risk factors on the slide here. Um It's difficult to say that particular risk factors cause particular conditions. But if you see any of these things in a question stem and some of the options are congenital heart disease and some of the options are not, you might be more inclined to think about congenital heart disease as an answer. Um The only one that's very specific is lithium use causing Epstein's anomaly um which is also known as atrialization of the right ventricle. OK. So I'm gonna move on now to the first question. So the way I'm gonna do this is I'll read the question out, give you guys a few moments to answer. Um And there'll be a poll so you're able to, you'll be able to do this. Um And then we'll go through the correct answer and um explain, explain the condition a bit more. Um So sorry, I'll, I'll start the po off again. Um So you're, you're shadowing the pediatric sho on a night shift. Um Your um the doctor gets urgently called to see a one day old baby who started suddenly deteriorating. Um So the baby appears cyanosed and you can see that saturations are 70 78% on air and these don't improve when the baby is given high flow oxygen. Um Baby was born at 40 plus nine by emergency c section. Um Apgar scores after birth were pretty good. So nine and then 10 and mum was known to have insulin dependent gestational diabetes. Um, but didn't have any antenatal scans. So we don't know what happened. Um So if you now want to, um, give your best um, shot as to what the answer is. Don't worry if you're not, you're not sure that's completely fine. Um, this is quite a complicated topic. So it's OK if you've not seen this kind of thing before, um but feel free to just have a go with the question. Oh OK. So um we've had five responses, so give it a couple more seconds. OK, great. So, thanks, thanks. Um Everyone who answered, um We're gonna move on to um the answer. So, um well, if you put transposition of the great arteries, um that's the correct answer. I'm gonna go on to explain um why that's the case. So the first thing with any, any question on congenital heart disease is I like to think about three things when I approach every question. So firstly, um how old is the baby? So, um there are different conditions that present at different time points. Some things present immediately after birth, some things present around the sort of one day mark, which as you remember from previous slides is when the ducts, arteriosis closes, some things present in sort of like 2 to 3 to 4 months like that kind of age group. And some things can actually be asymptomatic and be picked up incidentally when kids are a lot older or even as adults. That's the first thing to think about. The second thing to think about is whether the child is SINOS or whether they're not sinus. Uh This is kind of a key distinction in congenital heart disease and can really point you towards one thing on the other. Um And the third thing to think about is whether the question mentions a murmur. Um And again, that's um something that can point towards different conditions. So here we can see this is the one day old baby. So this is happening around the time the doctors, um doctor's closing and the baby is sinus. Um So what is TGA? Um So TGA or transmission of the great arteries is a um essentially a condition where um you would have two separate circuits of oxygenated and deoxygenated blood. Um So, instead of um the um obviously, the two circuits crossing over in, in normal life, um we essentially have a, a situation where there's no oxygenated blood being able to pass to the body. And obviously, if there's um no way that blood can cross between the right and left sides of the heart, this would not be compatible with life at all. Um However, what normally happens is that there's um there's either a um ventricular sac defect, an atrial septal defect or the ductus arteriosis doesn't completely close. And that's how we can move, maintain and onset symptoms after the closure of closure of the duct is that this is when suddenly there's a sudden drop in the amount of oxygenated blood that can pass the rest of the body. So, um you get this sinois and sats that don't improve on when given oxygen um around this sort of 12 hour mark. Um Other signs are, there's a loud s two heart sound and this is um I did look into quite a lot of things as to why this is the case. The only kind of good explanation I could find is that it's to do with the kind of anatomical positioning of the heart. And because um the aorta is a lot more close to the front compared to the pulmonary um pulmonary valve, um you can only hear this really, you can really hear the aorta and you can't really hear the pulmonary valve close. Um You might have a murmur if there's a VFD or an ASD, I'll go into what those murmurs sound like later on. But in this question, um there was no murmur. Um that was the question noted. So this baby likely was really only functioning cos it had a um patent duct and then when that closed started um started becoming gray sinos. Um key things that they might mention in questions as well is this egg on side shaped heart? It's like a globular shaped heart, but this only really develops in a chronic case. So in babies that don't have surgery and don't have adequate treatment, this can happen later down the line. So maybe at 5 to 6 months. Um and the management of it is very similar to many congenital heart diseases. So we give prostaglandin e to keep the duct open and then we need to do a surgery quite quickly in the first few days of life. Um, you'll see in later conditions that sometimes surgery is delayed if the medical management is like optimal or can be, um, can be enough to keep, um, a baby alive in kind of, um, in a good way. But unfortunately, with this condition, um, the only kind of good management that we have is surgery. Um, if we don't notice the symptoms, um, maybe because I've got a really big VSD or a really big, um ASD, this can actually lead to heart failure later down the line and you get, um, um, quite, quite severe RVH and L VH and then um, pulmonary hypertension. Ok. If anyone has any questions at any point, feel free to just drop them in the chat. Um, but if not, then I'm just gonna move on. Um Is there a link? Yes. So this is just generally gestational diabetes is a risk factor for m many congenital heart diseases. So it's not really specifically linked to this one, but I just kind of put it in there as a a point that OK, this likely is a congenital heart disease. Obviously all the answers about congenital heart disease. Anyway, so it wasn't really helpful but sometimes if they're giving you stuff like sepsis or um respiratory distress syndrome, other non cardiac things that could point you away from um a cardiac cause essentially. Ok. It should be hard to move on to the second question. OK, So we've got another SBA um stop pulling. Um I think that worked. Mm but did it work? No. Um ok. So sorry getting the right pole. Ok. So it's this ball. Perfect. So um another case of your shadowing the pediatric sho on a night shift um you're called urgently to see a baby who again, sats have been dropping um from birth and baby sinus and sats are now 78% on oxygen. Um and they're not improving when given oxygen. Um So on listening to the chest this time you do hear a murmur. So there's a loud pantoic murmur at the lower left dial edge. Um apart from that baby was born at 39 weeks, um we don't really have any results from antenatal scans. Um but mum says the pregnancy was normal and that she's got no health conditions and the situation. Ok. Mhm. Ok, great. So I'm just gonna now move on. Thanks very much for answering. Um So this is actually a case of tricuspid atresia So this was probably quite a tricky question. Um And it was kind of spite of different answers. I'm just gonna go through what this is, but I'm gonna break it down into a couple of levels. So firstly, um does wanna say in the chat, what the murmur, what the murmur is in this question, so we can hear this pansystolic murmur at the lower left spinal edge. Does anyone know what that what that is? No worries if you don't aortic regurg um first. So that would be um good thought. Um That's not quite what this one is. Um aortic R is more common in kind of adults. It's kind of to do with like age related changes to the valve or maybe um endocarditis or rheumatic fever or something in Children. More commonly people get stenosis or they get um kind of atresia. So just complete blockages of valves. Um This is actually a murmur of a ventricular septal defect. So this is typically a systolic murmur. Um and it's located kind of in the same place, um kind of where it's kind of in the same place as like the mitral area. So the lower lower left than or edge and it's, it's systolic mamm and essentially um it only occurs when blood is being um eject sort of forcibly ejected during Sicily. Um you get blood that moves from the left side to the right side of the heart. So it's described as a harsh um blowing, sometimes pansystolic murmur and it's quite, quite a loud murmur. Um So this is um kind of a two step kind of question. So firstly, identifying that this child has a murmur and the VSD is likely a shunt because the heart is basically just not working properly. Um So in Tricuspid atresia, what we have is that the Tricuspid valve is just completely blocked. So there's no connection between the right, right atrium and the right ventricle. Um So if this, if this occurred without any, any chance, so, um there was no VSD, if there was no patient DS arteriosis, um this would essentially result in a, a baby wouldn't be able to um survive to birth. So you have to have um a shunt with it. Um So what we get is that immediately from birth, there's gonna be progressive cyanosis. So, quite similar to the other case, but the, the sinois might be even more severe as you've got this complete blockage between the two chambers. Um There's gonna be a murmur of A VSD. There might also be a um patient duct as well. Um, investigations you might do so on a chest X ray, you might see an increased size of the right atrium on the right ventricle, um an echo. Um You might, you'll obviously see the Tricuspid valve just having no blood flow across it and you'll see a blood flow across the AFD or the VSD. Um So I'm not gonna go into too much detail about the management as you don't really need to know, um, specifically what they do, but essentially always prostaglandins initially. And then long term, there's a specific, um, um, a specific operation called the Fontan procedure, which essentially means that we try to divert any blood going to the right side of the heart. So we try to redirect all venous blood going straight to the lungs and this basically prevents the need for the use of the, the right atrium. Um This is only really a palliative procedure as well. A heart transplant would actually be curative in this situation. Ok. So um another question um just because of time I might not give um I might not do a poll here. I'll just let you guys think about it and then we'll just move on to the answer. Um ok, so we've got a five month old baby brought in due to failure to thrive. Um He was born at 38 plus two weeks to a 43 year old mother. Well, at birth and on the 73rd percentile. Um Now, so five months later, he's on the ninth percentile, he's feeling really poorly. Um He appears to want to feed but just can't really do so. Um And he does appear very small for his age, but currently he's not cyanotic, he's not tachypneic and he has an injection systolic murmur at the um upper, upper, right sternal border. So I'll give you a few moments to think about that. Ok. So, um this is a case of tetralogy of fallow. Um And the key thing to note here is the later presentation. So, while trichopi atresia and um transportation of the great arteries that presents with cyanosis from birth, um tetralogy follow, unless it's very severe, it only really starts presenting with cyanosis um around 5 to 6 months later. Um and something called at Bell, and we'll go into what that is um a bit later. So essentially, what is this? So it's to strategy. So it's four different heart defects all in one condition and they all kind of lead to the next one. So the first thing is pulmonary stenosis. Um and this essentially means that there's increased resistance to blood flowing to the lungs from the right ventricle. As a result of this, you get right ventricular hypertrophy. Oh What's what's it called? Um Right ventricular hypertrophy. Um basically because the right ventricle needs to generate a lot more pressure in order to force blood into the lungs. Um and this causes this boot shaped heart on an X ray if this condition isn't treated. Um then because um there's also a VSD um just um alongside all of this and due to the right ventricular hypertrophy, um if this kind of is per persists for a long time, um it actually means that the pressure on the right side of the heart um starts to exceed the pressure on the left side of the heart. Normally. Obviously, we know that left, the right ventricle is a low pressure, low pressure system, left, left ventricle is a high pressure system. Um And you actually start getting, instead of um a left to right shunt, you start getting a right to left shunt. And this is a key thing that causes the complications of the Trelegy or fall. Um And then the final thing is an overriding aorta, which basically means that the aorta originates from the area of the ventricles directly over the VSD. Um So you can see here, the aorta is just kind of passing all the blood, whether it's oxidated or deoxy thr through the body. And that's basically why Sinois happens cos you just don't have enough oxygen going to the body. Um So you can kind of appreciate from this picture that the more severe the pulmonary stenosis is the more or the more severe, the right ventricular outflow tract obstruction is um that means the condition will be more severe because you'll get more right ventricular hypertrophy, then there'll be more shunting of blood from the right to the left and then you'll get more and more deoxygenated blood going to the body. Um So in a very severe case, um this basically has happened already at birth. You've already got a lot of RVH and you get cyanosis um at birth, you might hear um a murmur of A VSD. Um, and um, you get sort of clubbing in fingers and toes in a few months due to like chronic under oxygenation of the extremities. Um, sorry, apologies here. They shouldn't, they, they shouldn't say VSD murmur, they should say pulmonary stenosis murmur. You actually don't really tend to hear the VSD murmur cos it's such a big VSD. Um, and this doesn't tend to really make a very loud murmur. Um In a less severe case, you tend to get um no sinus at birth cos sinus is only really presented, the stats drop below 80%. Um and you get a pulmonary stenosis murmur at birth, but this baby could actually be asymptomatic. So there might not be any action taken at this point. But what can happen is that the baby can present with something that we call a tet bell. Um So a tet bell essentially is sudden cyanosis when there's any increase in oxygen demand. And in babies, um babies essentially um only need a lot of oxygen if they're feeding or if they're crying. Um Those are the kind of two most sort of exercise that a baby will kind of do. Um what happens in this situation is that the heart will start pumping more and more blood, but this blood will be deoxygenated and the body won't be able to um won't be able to take this and the end result will be cyanosis. The baby will look blue um to manage t spells. Um There are several things we can tell parents to do. Um And they kind of rely on um trying to reverse that shunt. So, reversing the blood flowing from the right side to the left side of the heart and getting it to flow the other way again. Um So essentially the two things um both rely on increasing systemic vascular resistance. Uh So if you kind of think about it, if the systemic vascular resistance is higher, this means the pressure in the left ventricle will be higher. And then this pressure on the left ventricle will exceed the pressure in the right ventricle. Um and the shunt will reverse and the test that will go away. So what we can tell parents to do if their baby starts going blue and they've got um patrology of fallow is to lie them on their back and flex their knees. This actually um kind of kinks the femoral arteries in their legs. And when you do this, it increases vascular resistance and um helps to solve the problem. You can also give some um alpha blockers to actually cause vasoconstriction as well. Um Sometimes also beta blockers can be given as this kind of loosens up the right ventricular outflow tract, it loosens up the pulmonary um sorry, it loosens up. Yeah, the pulmonary valve essentially and um reduces um reduces the kind of root cause of the problem. But eventually really what we need to do is corrective surgery. There's no kind of medical treatment that will cure this overall. Um, and this is done in two parts. Um, and the first one is to actually just widen the valve. The second thing is to close the VSD and this is not surgery that's needed immediately straight after birth. As a baby typically isn't like very sick after birth, unlike in Atresia or in, um, transposition. Um, so we kind of do it at this kind of age as you just wanna prevent a very young baby going through um, a very brutal surgery. Um, but it's not really done later as you don't wanna let the baby be exposed to long term, um, low oxygenation for a very long time, which can lead to poor growth and development. Um, ok. Any questions about that at this point? Ok. Ok. So next question, um I'm gonna start the pole. So we've got a 10 year old boy who's been referred to the clinic due to suspected heart failure. His past medical history is unknown though. He was known to have a congenital heart defect at birth. And in the last two years, he's become a lot more fatigued. He's not able to run around with his friends and he actually starts getting breathless and goes blue sometimes and he's on the 10% overweight. So quite underweight. Um, when you examine him, you can see um positive hepatojugular reflux, some peripheral ankle edema. Um So kind of signs of um right ventricular um failure essentially. Um And he's not currently sinus at the moment though. And you can hear a harsh pantoic murmur at the lower left dial edge. So this is a slightly trickier question. It's kind of asking you to think about pathophysiology of the condition as opposed to just what the condition is. Um But if you wanna write on what you think is going on here, OK. So um gonna move on. So again, quite split. So we have um some people saying reversal of the left right shunt, some people saying coarctation and some people are saying pulmonary stenosis. Um So what's actually happened here is reversal of a left or right shunt. So thinking about all the murmur that the child has. So the harsh pansystolic murmur at the lower left spinal edge, that's something that we've already seen before in an earlier question. Um What do you think the underlying heart defect is in this child? You can, you can type in the chart BST. Yeah, perfect. Exactly. Um And what's happened now is essentially because this BSD has gone untreated for 10 years. Um It's led to a condition um called I and Mango syndrome where we basically get reversal of this left to right shunt and we have a right to left shunt and I can essentially explain why that happened. So firstly, I'll just talk about what A BSD actually is um I think we've touched on it already. But anyway, so um essentially V sds and PDA S. So, patent doctors, arteriosis are different examples of left to right shunts and this is an Ayano heart condition um unless it deteriorates and becomes iso manga syndrome. Um So VSD, we've mentioned what kind of murmur it is and um PDA you get this continuous machinery murmur. It uh it, it kind of is described as at the upper left spinal edge. That's kind of where the um the doctor's arteriosis is located um or kind of under the left C as well. Um And all these situations um we, we can um in PDA, we can give um so instead of prostaglandin, I should have said um Ibuprofen or some kind of um NSAID. So that will basically cause the P to close um as we need to antagonize the prostaglandin um or we can do surgical ligation um in a small VSD. Um Sometimes it actually just closes by itself and you don't need any treatment, but in the large BSD, like it's probably what's happened in this case. Um We do need to intervene. Um they can go into heart failure. So, diuretics can be given, you can give calorie supplementation as babies can kind of really struggle to thrive with um the BSD as they're just not able to really um kind of oxygenate their body. And then you need to, you do need to surgically close it. But what actually happens in ice and mango syndrome is essentially um this is when a acyanotic de defect can become a cyanotic defect. And what happens if A VSD isn't actually managed? Um So in A VSD in general, we have lots of sh lots of shunting of blood between the left and the right ventricles. Um every single time, um we have Sicily, so more blood is actually entering the right ventricle than should be kind of every cardiac cycle. So normally the right ventricle should only be getting blood from the systemic circulation. So, from the um from the veins, but you're also getting blood from the left, from the left side of the heart as well. And this right ventricle is just not really able to take this and it's not really designed to have such a high flow of blood going to it. Um So you get um you get increased blood flow to the lungs as well. Um Every single time this kind of causes damage to the lungs because you're just getting such high flows of blood into a capillary network that it's very delicate. Um This damage causes pulmonary hypertension and all of this just means there's a lot of backflow um sort of a lot of back pressure sorry into the heart. Um and you get right ventricular hypertrophy and this is kind of what happens inr of fallow. But as if you remember that is right ventricular hypertrophy caused by pulmonary stenosis. And this can in this situation, you have RVH caused by pulmonary hypertension, so damage to the pulmonary vascular network. And as soon as you get a significant amount of RVH, you actually get a situation like in urology of fallow in um severe te a fallow when the um pressure on the RV exceeds the pressure on the LV. And then you get the reversal of the left to right shunt, you start getting right to left shunting and you get um flow of deoxygenated blood to the systemic circulation and you get cyanosis. And that's essentially what happens if for 5 to 6 to 7 to 10 years, um we don't treat A VSD. Um and this is quite a severe condition and can really only be treated by kind of a heart, a heart transplant in this situation. So you really want to avoid this happening. Um So just got a um few more again for this one just in, in the interest of time. I'm not going to um do a poll for it, but I'm just gonna let you read the question. So you've got a crash call for a two day old baby girl who suddenly become very breathless and baby was born at around 38 weeks with no complications in pregnancy or delivery. Um Baby is um responsive. Um It's got normal itchy saturations but very, very high heart rate, um very high respirate, um low papillary refill in the um, lower limbs and centrally but normal in the hand, um, actual unrecordable BP in the lower limbs, but a normal BP in the upper limbs and importantly, the femoral pulses are not palpable. So, um, you might know what this condition is already, but given, um, given that, given the diagnosis, what do you think the most um, appropriate immediate management might be? But I can just do a poll just in case you wanna. And this is essentially a, a condition where even if you don't really know what it is, there's only kind of one management in in congenital heart disease. Very early on that. I've talked about in many, many conditions already. Yeah, so perfect. We have um a few people saying um B prostaglandin, which is um the correct answer. So this is a case of coarctation of the aorta. So this is actually um unlike many of the other conditions we talked about, this is actually an acyanotic condition. Um And essentially, I haven't got a picture of this one which is a bit annoying, but essentially the reason why this is acyanotic is that even though we've got a constriction of the aorta, we don't actually have any situation where there's any deoxygenated blood passing to the systemic circulation. Even though there's less blood passing to the systemic circulation, it's still oxygenated. So the baby's still gonna look pink even though it might be breathless and really struggling to breathe um this basically happens due to kind of a congenital defect. Um So there's like a inappropriate muscle tissue in the muscle of the aorta. And when the duct closes, it also causes the aorta to close too. And when this happens, you just basically just get no blood flow to the um to the lower limbs and to the lower extremities. So you get shock and you get heart failure, the baby can present with really severe lactic acidosis as you just have multi organs shut down. Um So in very severe cases, this can happen quite suddenly and quite dramatically at the sort of same time as the dot closes in less severe cases. The aorta doesn't really constrict enough to actually cause any symptoms. But what you do get is um a murmur. So very characteristic um systolic murmur. So every single time blood is ejected into the aorta, it kind of struggles to get through it and you can just hear a systolic murmur at the back cos that's where the aorta passes between the scapulae and you also get radiofemoral delay. So the radial p happens um just a few seconds, a few milliseconds before the femoral pulse um because blood is struggling to get down to the legs. Um Again, so we get a prostaglandin to keep the duct open. So that um essentially because the point of connection of the duct to the aorta is lower down compared to the coarctation. So even if the aorta is constricted, you still do get some blood going for lower extremities via the duct. Obviously, this will be deoxygenated blood. So it's not ideal, but it still kind of helped the situation a little bit and you need to do surgical correction in a very severe case. Um, ok, so I have run over a little bit with this, but this is a kind of the end of the congenital heart disease section. Um I think I'll just cut down the respiratory section a little bit because that is more simple and um with the slides you can read through it. But what I'll put here, what I've put together here is just a, a sheet, what I call a cheat sheet of just all the main conditions I've talked about um what they present as um key things that can be mentioned in an SBA question and then, um management and I split this into a cyanotic into acyanotic as this is a really good way in a question to just quickly differentiate or quickly rule out a few things. Um If you're kind of stuck about what the answer might be. OK. So I'm gonna move on to the rest conditions, I'll probably finish at around um five past or um 10 past seven. Just cos I did start a bit late and I wanted to make sure I did the cardio bit as thoroughly as possible. Um ok, so you got another um, S pa question just gonna start the pull. So sorry, it's a bit of a long stand. But we have a five month old baby boy brought to the GP by his mum. Mum's really concerned because he's had a sniffy runny nose and, um, she thinks that it's gotten worse after two days. So, on examination. And this is a really important bit to always read properly in a, in a rest stem. Um, he's alert, which is good. He's crying, which is also good has a normalish respirate on the high side though. Um, he's got some find the respiratory distress. He's got some intercostal and subcostal recessions, some tracheal tugging, but you can't hear any added sounds to his breathing. So there's no wheezing, there's no stridor, there's no gurgling, there's no grunting anything like that. Um, his capillary refill is less than two seconds, which is reassuring and apart from that seems to be pretty good. So he's not dehydrated, um, slightly raised temperature but nothing too dramatic. Um, neurologically seems pretty intact and abdom abdomen and everything else seems ok. Um, he is breastfeeding though. His feeds are taking a bit longer than they should be as he's just more irritable and he's had five wet and one dirty nappy in the last 24 hours. Ok. So, what do you think we should do in this situation? This is quite a fairly common stem in pediatrics. Well, they won't tell you what the diagnosis is or the question won't be about what's the diagnosis? It'll be about what, what we, what do we do here? What's the management um as in kids? There are so many subtle things that can point you towards one thing or another essentially. Ok. So I'm just gonna move on to the answer. In fact, first, does anyone type in the chat? What they think this condition is very, very common, pediatric respiratory condition? Yeah, perfect bronchiolitis. Great. So in this situation, what we would do is actually um the second option. So, and I'm gonna explain why that's the case. Um First, you're just gonna talk about what bronchiolitis actually is and then we're gonna go into the severity classification of it, which is the really, really important thing that you need to take home from this talk. So, bronchiolitis is a very common condition in babies. Um essentially happens due to um lots of pus and gunk and things like that filling up the bronchioles. Um when a baby just gets any kind of viral kind of cough vi viral fluy kind of symptoms. Um and it's basically the same viruses that cause this um that might be a not the question actually. But anyway, yeah, very um same viruses that cause this, that actually cause um adult um kind of the common cold but in babies um because their bronchioles are so, so small, even a small amount of parum gunk in the um in the bronchioles can actually reduce the flow of air quite significantly. Um I don't know if you've come across this equation in like preclinical med. But essentially the flow rate is inversely proportional to the is proportional to the to the radius to the power of four. So a very, very small change in the in the radius actually makes a really big change in the flow rate. And that's why this really, this affects very small babies, but babies tend to kind of grow out of it as they get older. So, signs and symptoms um very um commonly in these are all mentioned in the in the question stem. So we get respiratory distress. Um and if there's one thing that you need to sort of prioritize in pediatric learning is learning the signs of respiratory distress and knowing which are the really severe signs of, of respiratory distress. Um Sore rash essentially happens um because baby's not able to oxygenate um oxygenate um their blood effectively and there's trying to just get as much oxygen into their body as they can. Um So they're breathing really deeply, they're breathing really hard and they're not just using their diaphragm to breathe, they're using their intercostal muscles, they're using their accessory muscles in their neck. Um and they're just really, really going for it. Um in order to kind of just generate more pressure to um draw more air in and out of the lungs, they might purse their lips, there might be nasal flowering. Um and um there might also be head bobbing kind of in time to the breathing signs that point you towards more severe um respiratory distress is grunting. Um So this basically means the baby is really, really struggling with this breathing sinois. Obviously, as even with all of the other extra things baby's doing, it's still not able to maintain its SATS and any abnormal airway noises. So stride or gurgling, all kind of quite bad things. Um Other things of bronchiolitis is because the baby is struggling to breathe so much, it um really struggles to feed. So signs of dehydration are really important to look at. So that can be a reduced oral intake, a sunken anterior fontanel. So it's a soft spot on the baby's um forehead. Um a very dry mucous membrane. You can see this by opening the mouth and having a look at if the mouth looks quite dry and also um sort of the skin tiger and the capillary refill are really important. And if the baby is just struggling to feed and really struggling to breathe, it can also get um irritable if baby starts getting drowsy, that's when you're concerned as that's when you, you might be worried that it's not able to oxygenate, it's retaining CO2. And um that's quite a very severe condition. So, in terms of assessing the severity of bronchiolitis, um that's what most questions and most um osculations or anything really will really focus on. Um So in many situations, um babies can be managed at home as was the case in this question, but in any situation where um a baby has apnea, so any causes of stopping breathing, if they look really seriously unwell, and this can be really retelling if a parent thinks their child looks unwell, you should always take it very seriously. Um They've got any severe respiratory distress, like I mentioned, the grunting if their respirate is very, very high. So over 70 or they've got any central cyanosis as well. That's again, um signs to send them into hospital. And usually you just do this by a 99 ambulance. You don't tell a parent the child to A&E because this can take many hours. It might not go straight to A&E, you don't really have any control over that. But if you call for an ambulance, then you know, they're gonna be getting to A&E very quickly. Um and things that are kind of more of a gray area, but things that might point you towards sending a child to A&E is things like difficulty in breath, um difficulty in breastfeeding. So if they're not taking um at least 50% of their um of their oral intake, that's not very good. Um They look dehydrated and if their O2 sats, when you measure them are persistently a bit low, um those are things to kind of make you to push you towards referring to A&E. But if a parent, um if you think the parents are gonna be really, really on it and would be able to react to any further deteriorations, you might tell the parents to keep the child at home, but can give some very, very thorough and very strict safety netting in that kind of situation. And yeah, if we go back to SBA one, we can see the child didn't have any of these very severe features and that's why we can manage them at home. But with very clear advice and guidance, of course, in any situation, when you think a parent might struggle to look after a kid at home, if they've got three or four other Children, they might not really cope, it might be better to just tell them to better to send the child to A&E straight away just to prevent things from getting any worse. And obviously you make the decision based on, on every case. Um So what kind of safety netting advice would you provide? Um feel free to type anything in the chat? Yeah. Ok. I'm just gonna move on just cause of time. Um But some things that you will need to mention to parents are basically what you would do if things were to get worse. So developing red flag symptoms. So if the child starts to have any of these additional um airway sounds if their chest recessions get a lot worse if they drop their fluid intake. Um, they just look exhausted, they're not really able to respond to you. They're getting really drowsy. Um, and another thing to mention also is that, um, smoking is obviously gonna exacerbate these symptoms and trying not to smoke around the baby and even just doing smoking cessation counseling with parents can be quite a good idea. So, just another, um, quick question, I won't really spend too long on this. But what is bronchiolitis caused by? Yeah, perfect. So everyone's saying R SV, which is great. So R SV is basically a virus that causes the common cold in older adults and Children. Um but in babies, it can cause all these problems that I've mentioned. Um because of the very small bronchioles, um there are obviously no medications to directly treat it. We can't give antibiotics cos it's not bacteria and management really just involves giving supportive treatment with anything that's compromised. So if they're not able to oxygenate properly, giving them supplemental oxygen, um if they're not able to feed properly, you might need to insert an NG tube to kind of make sure that they're not gonna get so dehydrated. Um Just some other quick true or false questions. Um You can just type this in the chart. So all, all babies with bronchiolitis need a capillary blood gas if they're requiring oxygen. Um You can just put in true or false, false. No false. Yeah. Perfect. Very good. So yeah, this is false. So in general pediatrics, we try to avoid sort of upsetting Children unnecessarily if we can help it. Um blood gas isn't really gonna give us any information that will change the management. The management is basically based on clinical signs. Um and something to note is that nice guidelines do state that if babies have worsening respiratory distress when you're giving them high amounts of oxygen. So over 50% oxygen or you're really suspecting impending respiratory failure. So just apnea, then a blood gas might be might be helpful, but this is very, very specialized and very unlikely to be kind of commonplace. Ok. So another true or false there is a vaccine against bronchiolitis, right? Yeah. So and someone else said false. So again, very good. So there is no vaccine against bronchitis. Um there is however, this monoclonal antibody called paveli. Um this is something that is um given as injections to babies that are high risk of developing bronchiolitis. So, babies are down syndrome because of abnormalities in their respiratory system. Congenital heart defects. If they get bronch, they're gonna gonna get hit harder, just cos their heart's gonna be working a lot harder than it should be. Um This is obviously not a vaccine as it doesn't stimulate the body to develop its own antibodies. You have to keep giving it every so often in order to boost the antibody levels to a good enough level to treat to sort of prevent bronchiolitis essentially. Ok. So, um, just another s pa I'll probably just go on about 10 past and I'll just leave, leave it there with how much I've covered. Um, so repeat fy two. Um, have I got the right question? So, next child is an 18 month old boy who is, um, presenting cos his parents are concerned. He's been getting on well for about three days and it's actually getting worse. Now, he's quite distressed. He's crying loudly. You can see these marked intercostal and subcostal recessions and he's got a loud barking cough and very stridorous breathing. So, um what is the most likely diagnosis? Yeah, and we have 100% of people all say croup, which is correct answer. Brilliant. So again, this is not a pretty, a pretty um um straightforward question because of the things that we mentioned. So we've got the bar and the stridorous breathing very rare, classic signs of croup. So, croup is a condition that instead of affecting the bronchioles, it affects slightly higher up. So it affects the larynx or the voice box. And you can see here in the picture that the normal larynx, um obviously a lot of space, a lot of um a big hole for air to come in and out essentially. Um But in inflamma in inflammation in, in infection in this area, it goes um because this is the main place where I get in and out of the lungs. Um, there's a lot of ok. And you so noise when you're trying to force air. Um, um, something really important in, um, group is understanding the severity classifications. This is, um, something called the Wesley, the Wesley classification. Um, and that, it point that looks at are kind of how severe the child is working or how much respiration distress is actually going on. So mild group, the child actually would be, um, pretty calm. They wouldn't be coughing much at rest. They're happy to kind of do their normal activities. They'll be running around, they'll be playing. You might hear an occasional barking cough but not really much more than that. And they would definitely not have any stridor. Then it, if you move over to severe group, you actually start getting really, really bad inspiratory stridor and you might even get expiratory stridor as well. Very severe respiratory distress and you actually might start getting more, more systemically unwell as well. So tachycardia and you start dropping your stats as well. Ok. So true or false steroids are the mainstay of management in group. You can just put this in the chart. True. Yeah. Perfect. Yeah. So they are, um, we normally give dexamethasone orally. So you might, I always thought it was a little bit or like counterintuitive if someone's got breathing problems, but obviously they can still swallow and it's just more, it's nicer to give kids something oral than giving them something IV or something inhaled. They just don't really like it. A more severe croup. You can give nebulized bide or nebulized adrenaline as well. Um, something that can come up quite commonly is you get an A two E station and AY with Croup. Um, you get this kid with a barking cough with dry or, or the main thing to do is just not to, not to touch a child, not to agitate the child, not to upset the child. Um, making sure that you're obviously doing your assessment from the end of the bed as much as possible. Um, and at the end of the A two E, they can get you to do some prescribing. Um, so I've got a little prescribing case. Um, I'm not sure I'm gonna go through it now just because of, or I'm not gonna get you guys to do it now just because of the time. But what can happen is they'll basically just give you, give you the child, they'll give you the obs. Um, and from that, you can kind of think about how severe the group is or they might even tell you like it's mild group. Um, they'll tell you what the weight of the child is and they'll just say prescribe any appropriate medications and they won't tell you what medications specifically you need to prescribe. So that's when you'll need to know about, um, the fact you need to give oral Dex, um, and important thing to note in pediatric prescribing is that the CBN F is a little bit more complicated than the adult BNF. So it always tends to give a dose either by weight or by age. So improve, it gives it by, by weight and it's 1 50 mcg per kilogram per dose. Um Remember this is micrograms, not milligrams. Um And another thing to point out with kids is that you never give tablets to kids that are like under 10, you always give an oral, oral solution. So when you worked up the dose by just multiplying the dosing by the weight, you can then scroll. So in the B NF on the kind of far right, you get this medicinal forms and pricing area and you can see all the different formulations of the medicines. It might come in like IV it might come in oral tablets, it might come in oral solution, just make sure you give the right kind of preparation and you know that you need to give 1800 mcg. Um Oh, sorry. So you just basically convert this into the correct number of mils. Um So here I've written dexamethasone, written the actual solution that I wanna give. I've converted the dose to milligrams here just to make it a bit easier when you're administering it cos this is given to milligrams. Um And then I have said the number of mils it would be as well. This would also be an SBA question when they give you all this information and get you to calculate what the meals would be or something like that. So again, it's not too complicated. It shouldn't really, um it shouldn't really trip you up if you remember these two things. So making sure that you're dosing by weight and making sure that you're giving a child under 10 years, an oral solution, not a tablet. Ok? So something else that's kind of similar to the previous case, but just a bit different. Um So I was gonna stop the po so we've got a two year old with sudden um not sudden with stridor, severe respiratory distress and drooling fairly subacute over five. OK. Great. So we've have um everyone going for option three, which is the correct answer. Um So this is a case of epiglottitis. I'll explain what that is in more detail, just just in a second, but just why it isn't the other answers. So, Croup, this is kind of similar to Croup and that is gonna present with Stridor as well. But croup would not present with drawing um Titi you have very, very severe upper airway obstruction and even saliva, you find it difficult to swallow. That's where you get drawling. Anaphylaxis would come on. Come on over a minute. You might have Stridor as well, but you, this would just be a much more acute presentation, Quinsy. Um This is the one that actually has the most overlap. Um, but actually this tends to be in older Children and adults and you might also have Trismus, which is basically kind of a, um, unequal smile and difficulty opening the mouth and I'll go into a bit more about that as well. And asthma you wouldn't really have stride or you'd have wheeze as this is a lung problem, not a, not like a upper airway problem. And you would obviously give yourself salbutamol than that. So, epiglottitis, I didn't actually realize how severe it was until I kind of looked at pictures of it. It's basically swelling of the epiglottis, which is a kind of flap of cartilage that covers it over the larynx every single time you swallow to prevent you aspirating into the lungs. And normally it looks like this, you can see your vocal cords nicely nice and open here. And in epiglottitis, the whole thing is just completely blocked up and you're trying to tube someone and you can't even see, you can't even see where you're going. Um It's caused by um in it's like this is this is caused by a bacteria. Um So it's caused by hemo haemophilus influenza type B. So specifically type B something to just note, um and this is something that kids actually get vaccinated against. Now, so questions terms might mention that the child is unvaccinated. Um Interestingly, it's now more common in adults as a, as a as compared to Children as um Children are now vaccinated against it in the UK. So adults that might have missed that are actually more at risk. Um And unlike things like croup and bronchiolitis, it doesn't really have an age preference, it can affect anyone. So adult or child doesn't really matter. Um signs it can present with can be. Um, so obviously signs of very severe respiratory distress, um Stridor drooling and something called tripoding, which is when the child just kind of leans over and places their hands on their, on their like um shins. Um and this is just a way for them to get as much oxygen as they can into their lungs. Um Something really, really important to note is that if you suspect this condition and you should never examine the child or distress the child as this can actually just cause a full obstruction and prevent them from breathing altogether and cause them to go into respiratory arrest. Um And examination won't really cause won't really show anything anyway, as because all the obstruction is actually sort of behind the level of the mouth, the mouth actually might just look normal. This is in contrast to Quinsy. So, Quincy might present with very similar symptoms to epiglottitis actually. So drooling high fever, a sore throat, but Quinsy, they typically have more um fewer respiratory distress kind of symptoms. And if you do open the mouth, you do see uveal a deviation, you'll see big tonsils as well. Um You need to call for anesthetic support immediately as a child might need to be intubated in this situation. So I'm gonna skip over this because it's a very, very niche point. But just essentially just to, to note that the p and it's just a bit of annoying thing just to like, memorize it, but it's just something to point out and the HIB vaccine is given um, quite a few times in childhood. So it's given as part of the six and one and then it's given again at the same time, you give the mmr um as part of the HIB men C combined vaccine. OK. So I think I'm gonna stop there just cos I've gone over time now and it's um obviously um quite late on a Thursday evening now. Um My next little bit was an asthma and that was just the end of the presentation. Um I'm just gonna see if there's anything just at the end to cover. Yeah. So this basically just goes into asthma um differentiation between viral induced wheeze and asthma. And then looking into like the resource council guidelines of how to manage asthma. Um This is this obviously asthma is really high yield and come up in ba S and come up in OS stations. So just make sure you have a, have a look through these slides if you're interested. Um I've gone into how asthma attacks are managed, also gone into how asthma is classified and how we diagnose asthma in Children as well, but I'm just not gonna go into it all now cos it will take another like 10 minutes and um I want to let you guys go home before um quarter past. Um Does anyone have any questions um about anything I've talked about so far? Oh, it's so if you wanna, I'll stick around for a bit. Oh, thank you. Um uh Thanks very much for coming. Something to just point out is um other pediatric respiratory and cardio things to know about. So these are the ones I haven't covered. Um Anaphylaxis obviously very, very common. Like I wasn't gonna cover it, just cos you probably know about it already. Um asthma. Um I haven't covered it today but just go over and read it again. Cystic fibrosis. Um S VT in kids is quite common and also cardiac arrest. Yeah, that was everything I'm gonna stick around for like five more minutes if anyone has any more questions. Um I know the first is there a feedback form you can upload? So I think you're gonna get emailed a feedback form by the organizers of teaching things um shortly. So you'll, you'll be getting that. Um So yeah, don't worry about that now, but yeah, thanks very much for coming. Um I know it was quite intense and some of the questions at the start were quite hard, but thanks very much for giving it your best shot and hopefully you learned something. Um, I definitely learned a lot when I was making the presentation to be honest. Um, yeah.