Sandbox:Asra

Asra Firdous,M.B.B.S.[1]

Vomiting

Vomiting in Children

Characterization of Vomiting: ❑ Onset (Abrupt or gradual) ❑ Frequency (persistent or occasional) ❑ Duration ❑ Vomitus content (bile, blood) ❑ Volume ❑ Effect on oral intake ❑Projectile vomiting ❑ Relationship with food

Obtain a detailed history of associated symptoms ❑ Age (common causes of vomiting varies with age) ❑ Past medical history (recurrent episodes, Diabetes Mellitus) ❑ Any history of surgeries ❑ Medications/Foreign body ingestion/Poisoning ❑ Menstrual History (Pregnancy should be excluded in all women of reproductive age)

Elicit the epidemiological factors ❑ Travel before the onset of illness ❑ Exposure to contaminated food or water ❑ Illness in other family members

Examine the patient: Assess the volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑Respiratory rate ❑ Eyes ❑ Mucosa Perform a general physical exam: ❑ Skin ❑ Pallor ❑ Jaundice ❑ Dehydration ❑ Inspection ❑ Signs of previous surgery ❑ Abdominal distension ❑ Abdominal pulsations ❑ Abdominal peristalsis ❑ Auscultation ❑ Decreased bowel sounds  :❑ Increased bowel sounds ❑ Palpation ❑ Abdominal tenderness ❑ Rigidity ❑ Guarding ❑ Abdominal mass ❑ CVA tenderness ❑ Rovsing's sign ❑ Psoas sign (suggestive of retrocecal appendix) ❑ Obturator sign ❑ Digital rectal exam (tenderness may be present in retrocecal appendicitis) ❑ Testicular examination in males ❑ Cardiovascular system ❑ Respiratory system ❑ Anorectal (bleeding)

Order routine laboratory tests: ❑ CBC and differential ❑ ESR ❑ Serum electrolytes ❑ Urinalysis

❑Assess vital signs ❑Obtain venous access

Unstable

Stable

Stabilize hemodynamics

History and Physical Examination

Regurgitation

True Vomiting

Reassurance and follow-up in OPD

Red flag signs ❑ Unstable vital signs ❑ Acidotic breathing ❑ Bile and Blood present in vomiting ❑ Clinical features suggestive of GI obstruction ❑ Inconsolable cry and excessive irritability ❑ Altered sensorium

Yes

No

❑ ICU admission ❑ Stabilise ❑ Investigate for the underlying cause

Fever

Treat the underlying cause

Present

Absent

Infections

❑ Frequency of vomiting ❑ Effect on oral intake

Treat the underlying cause

Persistent/Recurrent vomiting Hampering oral intake

Occasional vomiting Not hampering oral intake

Antiemetics ❑ Ondansetron ❑ Domeperidone

Observation and Reassurance

Ewing's sarcoma Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [3];Assistant Editor(s)-In-Chief: Michael Maddaleni, B.S., Asra Firdous, M.B.B.S.

Overview

Ewing's sarcoma is the second most common malignant bone neoplasm commonly affecting children and adolescents. It usually affects patients in the second decade of life with a peak incidence around 15 years of age. It comprises 3% of all malignancies in pediatric patients and about 10-15% of childhood bone cancers. The overall incidence of Ewing's sarcoma is approximately estimated at 2.9 cases per million population in the U.S. Ewing's sarcoma is more common in males than females. It is more prevalent in whites than Africans.

Epidemiology and Demographics

• Ewing's Sarcoma is the second most common bone malignancy in children and adolescents.
• 10-15% of childhood bone cancers are Ewing's Sarcoma.
• Ewing's Sarcoma constitutes about 4% of pediatric cancers.
• 200-250 new cases of Ewing's sarcoma are reported each year in the United States.
• Nearly, 60% of the Ewing Sarcoma cases have long-term disease-free survival.

Incidence

• The incidence of Ewing's sarcoma has remained unchanged for 30 years.
• In the United States, the overall incidence of Ewing's sarcoma is 1 cases per million individuals.
• During 1973-2004, the average annual incidence of Ewing's Sarcoma was estimated to be 2.9 cases per million population in the United States.
• The incidence of Ewing's Sarcoma, in the United States, is estimated to be 200-250 cases annually.

Mortality/Morbidity

The overall 5-year survival rate for patients with Ewing's Sarcoma is approximately 70% in primary lesions and 30% in metastatic disease.

Race

• Ewing's Sarcoma is more prevalent in Caucasians than Asians or Hispanics.
• African Americans and Africans are less likely to develop Ewing's Sarcoma.
• The incidence in the Caucasians is 1.5 cases per million population.
• The incidence in the Asians is 0.8 cases per million population.
• The incidence in Africans is 0.2 cases per million population.

Age

• Ewing's Sarcoma commonly affects children and adolescents between 10 and 20 years of age.
• The median age at diagnosis is 15 years
• In patients younger than 5 years, diagnosed in about 0.6 cases per million population.
• In patients aged 10-14 years, diagnosed in about more than 5 cases per million population.

Gender

• Males are more commonly affected than females. The male to female ratio is around 3:2.

Anemia of Prematurity Symptoms

The majority of patients with Anemia of Prematurity are asymptomatic. In premature infants with severe disease, symptoms are usually vague or non-specific.

• Common symptoms of Anemia of Prematurity include
  • Tachycardia
  • Tachypnea
  • Decreased activity or lethargy
  • Difficulty feeding
  • Pallor
• Less common symptoms of Anemia of Prematurity include
  • Poor weight gain despite adequate calorie intake
  • Breathing difficulties
  • Metabolic acidosis due to increased lactic acid production from anaerobic metabolism in the cells
  • Heart murmurs

Pathophysiology of Anemia of Prematurity

The pathogenesis of anemia of prematurity is multifactorial. Anemia of prematurity is the result of a combination of decreased erythropoietin production, increased erythropoietin metabolism, deficient iron stores, decreased RBC lifespan, and blood loss during phlebotomy.

Physiological anemia in newborns

Normally, all the newborns experience a fall in the haemoglobin concentration during the first few weeks of life. Healthy, fullterm infants usually develop anemia around 10-12 weeks of life after birth. Hemoglobin concentration never falls below 10 g/dl in healthy infants. Physiological anemia is well tolerated by and does not require any therapy.

• After birth, an embryo transitions from a hypoxic state in-utero to an infant in a relatively hyperoxic environment
• This transition leads to an increase in blood oxygen and tissue oxygen concentration in newborns
• Increased oxygen concentration inhibits erythropoietin production and eventually stops erythropoiesis
• Due to the rapid growth and disproportionate RBC production, hemoglobin levels fall gradually in infants
• The drop in hemoglobin concentration continues until the tissue hypoxia develops which usually takes around 6-12weeks after birth
• Tissue hypoxia activates the oxygen sensors present in the kidney and liver to stimulate the erythropoietin and red blood cells production
• Fullterm newborns have enough iron stores for erythropoiesis until 20 weeks of life
• Infants have a shorter RBC lifespan and increased erythropoietin metabolism when compared to adults

Pathological Anemia of Prematurity

In preterm infants, multiple physiological factors exaggerate and combine to result in pathological anemia. Hemoglobin levels drop rapidly to less than 10 g/dl around 4-6 weeks after birth. Infants with 1-1.5 kg of birthweight have hemoglobin levels around 8 g/dl, whereas infants with birthweight less than 1 kg have hemoglobin levels around 7 g/dl or less. The profound decrease in hemoglobin levels in premature infants produce abnormal signs and symptoms and require a blood transfusion.

• Iron transport from mother to infants and a greater proportion of fetal erythropoiesis occur during the third trimester. So, infants born prematurely have deficient iron stores required for the red blood cells production
• Blood loss during phlebotomy is the major contributor of anemia of prematurity
• Majority of preterm infants are sick and critically ill that require frequent blood sampling for various laboratory investigations needed for their clinical monitoring. The average amount of blood loss during sampling ranges from 0.8-3.1 ml/kg/day, a significant amount that requires replacement
• Preterm infants are at increased risk of nosocomial infections that lead to oxidative hemolysis
• In premature infants, liver is the major site of erythropoiesis. Liver EPO is less sensitive to anemia and tissue hypoxia
• Preterm infants have deficient Vitamin E, Vitamin B12, Folic acid stores required for red blood cells production
• A combination of blood loss, decreased erythropoietin production, deficient iron stores, increased erythropoietin metabolism, shortened RBC lifespan contribute to the development of anemia of prematurity

Vomiting

❑Assess vital signs ❑Obtain venous access

Unstable

Stable

Stabilize hemodynamics

History and Physical Examination

Regurgitation

True Vomiting

Reassurance and follow-up in OPD

Red flag signs ❑ Unstable vital signs ❑ Acidotic breathing ❑ Bile and Blood present in vomiting ❑ Clinical features suggestive of GI obstruction ❑ Inconsolable cry and excessive irritability ❑ Altered sensorium

Yes

No

❑ ICU admission ❑ Stabilise ❑ Investigate for the underlying cause

Fever

Treat the underlying cause

Present

Absent

Infections

❑ Frequency of vomiting ❑ Effect on oral intake

Treat the underlying cause

Persistent/Recurrent vomiting Hampering oral intake

Occasional vomiting Not hampering oral intake

Antiemetics ❑ Ondansetron ❑ Domeperidone

Observation and Reassurance