1. To r/o dehydration in a toddler: check for tears, slobber, at least 3 wet diapers a day. If a toddler is sick, its ok if he doesn't eat (as long as he has enough body fat and isn't a real skinny minny kid), but he needs to drink.
2. Pneumovax (23-valent s.pneumo vaccine, covers 90% of all disease causing variates) is a polysaccharide vaccine and thus is not immunogenic enough to have any response in children under the age of 2. It's indicated in people over 65 and in children 2 years+ who have an increased risk of s.pneumo (i.e. asplenics/sickle cell, acquired immunodeficiency including HIV/chemo/radiation/transplant recipients, congenital immunodeficiency including complement deficiency and phagocytic disorders, heart/lung/renal failure/diabetes).
In kids under 2 years, we use prevnar, which is a 13-valent, protein vaccine-- each antigen conjugated to CRM-197 which is a non-toxic mutated diptheria toxin protein (single AA mutated glu->gly)
3. Vaccines!!
Rota: 2/4/6
Hib: 2/4/6, 1 year (or 15 mos)
Prevnar: 2/4/6, then 1 year.
DTaP: 2/4/6 mos, 1 year (or 15 mos), then 4 years
Polio (salk): 2/4/6, then 4 years
Hep B: birth, 2 mos, 6 mos.
Hep A: 1 year, dose #2 given 6 mos after dose #1
MMR: 1 year, 4 years
VZV: 1 year, 4 years
Gardasil: 9-11 years, and then dose #2 (2 mos after dose #1), dose #3 (6 mos after dose #1)
Flu shot: 6  mos for attenuated vaccine, 2 years for live (nasal spray). 2 doses 4 weeks apart for kids <9 getting the shot for the first time, or if their last year's shot was the first time and they only got 1 then.
4. Catch up vaccinations... too complex to memorize. Important points:
-once they hit 5 years, they're too old for prevnar/HiB.
-once they hit 15 weeks, they're too old to start rota
You're never too old for the other ones! Sorry kids.
5. Differential for ALTE:
-Neuro: seizure/post-ictal, increased ICP (bleed/fluid/mass), breath-holding spells-- can be cyanotic (due to tantrum) or pallid/non-cyanotic (due to pain/trauma/fall). 6 mos to 6 years is age range.
-Pulm: RSV, pneumonia, pertussis
-Cardio: bradycardia (congenital long QT), ductal-dependent congential heart defects can decomp really fast, tet spells.
-GI: GERD-- unclear whether GERD -> choke -> apnea, or apnea -> LES relax --> GERD, congenital swallowing problems/TEF.
-Gen: sepsis, toxin (CO poisoning, botulism toxin, opiates), inborn errors of metabolism
6. Tricuspid valve atresia: congenital absence of the tricuspid valve. Most of the time (80%) there is muscle where there should be valve, most of the rest of time time it's membranous; rarely, there will be a valve with fused cusps. The real problem is that nearly 100% of the time there's concomitant hypoplastic R heart, so you're essentially facing a kid with only one ventricle. ASD and VSD are mandatory for survival. There's lots of mixing and the neonate will be cyanotic. 75% of the time, there is also inadequate blood flow to the lungs 2/2 pulm artery stenosis or outflow tract obstruction or VSD being small.
7. Surgery to fix TVA:
--(1, done in neonate) Make sure there is blood flow to the lungs.Connect the aorta directly to the pulmonary artery (Blalock-Taussig shunt). Other surgery you may need to do: make sure VSD/ASD stay open, fix any pulmonary artery stenosis/obstruction. In the case where there is too much flow to the lungs, you may need to band the pulmonary artery to prevent pHTN/high-resistance pulm circuit. The final surgery to fix TVA depends on there being a pressure gradient from SVC to pulmonary arteries.
--(2, done @ 3-6 mos) Connect SVC to pulmonary artery (glenn procedure), remove your old aortic-pumonary shunt. At this point, blood from IVC is still going to R atria through the ASD to the left side, where it is mixing with freshly oxygenated blood. The kid will still be cyanotic.
--(3, done @ 2-3 years) You shunt blood from IVC to pulmonary artery (fontan procedue). You can either connect the R atria to the pulm artery, or you can do an extracardiac fontan and directly plug IVC to pulm artery with a tube. If the systemic pressure is higher than pulmonary artery pressure, great! Sometimes you can have too much flow into the lungs and cause edema-- you can put a hole between IVC and atria to relieve it. The problem is that if there is high resistance in the pulmonary circuit, blood from VC may not be able to enter. Kids with a mean pulm artery >15 are not candidates for Fontan procedures. Don't forget that going on bypass causes increased resistance in the pulmonary circuit.
8. Long term problems of Fontan procedures:
-People do great until about 20-30 years out, there is a significant increase in mortality.
-CV: arrhythmias, sudden death
-Pulm: Restrictive lung disease
-Coags: hypercoagulability, 41% incidence of atrial mural throbmi, although most are silent. ASA and well-monitored coumadin have comparable outcomes, both better than badly-monitored coumadin.
-Chronic venous stasis
-Renal failure (50% of people have at least mild renal failure)
-Hepatic dysfunction.
9. Transplant is not a great solution for people with TVA-- too few hearts, and lots of early mortality compared to Fontan, where early mortality is ~5%.
10. You don't get pulmonary edema in cases of hypoalbuminemia because the lung epithelium are permeable to albumin, so its hard to create an oncotic pressure gradient with changes in albumin concentration. Perhaps this evolved so that our lungs wouldn't flood every time we went through a period of starvation? Food for thought... (source: SMG)