1. The cutoff between epi-pen (0.3 mg) and epi-pen JR (0.15 mg) is 30 kg body weight. Epi-pen Jr goes to kids 15-30 kg.
2. Pediatric shock protocol:
-Make sure you have an airway, intubate if needed. Infants: towel under shoulders, head in sniff position. Young kids: towel under head, neutral position. Older kids/adolescents: the older they are, the more you hyperflex the neck back. Inbutation tube size: (age+4)/4. Intubation tube depth (cm): tube size * 3. In patients where you're worried about increased ICP, do not use ketamine (worsens ICP).
-Determine if you need fluids (cap refill, pulses, HR, UO). If so, get IV access: if you can't get a line in 90 seconds or 3 tries, go to IO line. Best place to put it: antero-medial proximal tibia, where it's flat. In older kids, you can do distal tibia a few cm above medial malleolus). Lidocaine to periosteum if you have time. Put needle in, when you get to bone, push/twist until you get to marrow. Aspirate to check you're in marrow-- you can use the marrow to do labs (T&S, etc). You will need to put pressure on the bag to get fluids in, and keep pressure to prevent the line from clogging up. Put in some heparinated saline, check for extravasation into tissues-- if you're in subQ tissue, you can cause compartment syndrome.
-Resuscitate with 20mL/kg isotonic NS boluses, as fast as you can. Can repeat twice, up to a total of 60mL/kg. If they are still in shock, consider pressors/inotropes if they are in distributive or cardiogenic shock, and blood if they are in hemorrhagic shock.
3. Prophylactic treatment for contacts of neisseria meningitis/sepsis patients: rifampin or IM ceftriaxone for kids, cipro for adults.
4. Absence seizures can be triggered in office by ~2 mins of hyperventilation. Useful for confirmation of diagnosis, in the office or during an EEG.
5. DDx for seizure in a 2 y/o:
--Gen: fever, trauma, pseudoseizure.
--Tox: diabetes meds, b-blockers, cocaine, alcohol (withdrawal), AED, tricyclics, INH (B6 deficiency), lithium
--ID: meningitis/encephalitism, brain abscess
--Neuro: epilepsy, tumor, hemorrhage, increased ICP, tuberous sclerosis, stereotyped mvmt assoc with autism
--Endo/Met: hypoglycemia, DKA, hypocalcemia, hyper/hypoNa, vitamin A excess, vit B6 deficiency
6. Management of febrile seizures:
--LP: <6mos: indicated. 6-12 mos: indicated in the absence of clinical sx suggestive of meningitis only if HiB/S.pneumo (PNV13) vaccines are incomplete or they are on antibiotics that could mask meningitis symptoms,  >12 mos: indicated only in the presence of clinical sx suggestive of meningitis
--Imaging: not indicated, unless there is a hx of trauma, an enlarging/very large head suggestive of hydrocephalus, focal neuro deficits, abnl neuro exam, or signs of increased ICP.
--Labs: not helpful in the setting of febrile seizures. Indicated only if there is reason to suspect electrolyte abnormalities as the cause (i.e. lots of diarrhea/vomiting, excessive water intake e.g. over-dilute formula)
--EEG: not indicated, especially hours after the seizure is over. Most likely to find abnl findings right after seizure, does not influence treatment.
--Treatment for febrile status epilepticus: Diastat (rectal suppository of diazepam, give 5 minutes after seizure begins).
7. Anticipatory guidance about febrile seizures/status:
--don't let the child be unsupervised in any activity where if he seized, he'd be in danger (i.e. in the pool/tub, riding a bike/monkey bars, don't let him sleep in upper bunk, etc)
--no spoon in the mouth. Clear the area around, don't try to stop the movements just let them seize.
--incidence of epilepsy in kids with febrile seizures is about 2% vs that of the general population at 1%.
8. In evaluating septic joints in kids, think Kingella. More common in kids less than 4, but can happen in other age groups. Most often affects knee and hip. Other pathogens to consider: staph aureus, neisseria, salmonella in kids with sickle cell.
9. It used to be believed that HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella) organisms were the most common cause of culture-negative endocarditis, presumably because they were difficult to culture, but studies have found that they are in fact easily cultured with current techniques as long as you wait for at least 5 days. A large, multicenter trial (n=407) of presumed culture-neg endo found 0 cases of HACEK organsims. Another trial (n=348) of presumed culture-neg endo in France managed to get a positive culture in 79% of cases, and the top etiologies were: coxiella burnetti (48%), bartonella (28%), strep (4%), t.whippli (2%), However, it should be noted that Q fever is much more common in France than in other countries.
10. "Idiopathic pulmonary hemosiderosis is a rare disease found primarily in children that causes recurrent episodes of diffuse alveolar hemorrhage. Recurrent alveolar bleeding may eventually produce pulmonary hemosiderosis and fibrosis. Diffuse alveolar hemorrhage is characterized by hemoptysis, dyspnea, alveolar opacities on chest radiographs, and anemia and can result from a variety of underlying conditions.... When no underlying cause for repeated episodes of diffuse alveolar hemorrhage is apparent, the entity is referred to as idiopathic pulmonary hemosiderosis (IPH)" -uptodate