Commonest: Case scenarios will be given...Drugtherapy will be part of the question.

Which drug is to be used?

Write the Prescription. (weight and age of the childgiven)given)

eg: Write drug therapy for a 2yr old male child, 15 kgwith tuberculous meningitis according to IAPguidelines.

Mention second line drugs if sensitivity resultsshows e/o MDR TB.

http://indianpediatrics.net/dec1997/1093.pdfhttp://indianpediatrics.net/dec1997/1093.pdf

Drug therapy as a part of standard protocol canbe asked…

eg: Write flow chart for pulseless arrest in a threeyear old child following accidental drowning…year old child following accidental drowning…

Tip: Know your PALS, NRP guidelines, IAPguidelines and flow charts pit pat…. No room forerror.

Specific drug can be asked…

Classification, chemical structure, Indication,dose, side effects, normal drug level…etc.

Tip: Newer drugs like Oseltamivir or drugs withcomplicated dosing schedule like digoxin are mostlikely.

Question on safety of drug in a specific situationis a possibility..

Pregnancy categories, Breast feeding safety, Usein G6PD deficient patients..etc.in G6PD deficient patients..etc.

Tip: Harriet Lane handbook gives a good chapter of“special drug topics” in the end.

OSCE question on specific situations involvinguse of drugs..

Post exposure prophylaxis for HIV

Malaria prophylaxis for travel Malaria prophylaxis for travel

Therapy for perinatal exposure to maternalvaricella or maternal syphilis…etc.

Pharmacologic prophylaxis for “H1N1 Novelflu of Swine origin” contacts.

Specific antidote therapy for common drug overdosing withdoses and schedule can be asked…

Paracetamol

Opiates

OPP OPP

Calcium channel blockers

Beta blockers

Digoxin

Benzodizapines

Lead poisoning

Iron toxicity

Heparin

A 3yr old male child involved in a fall from 4th

floor, injured his back, L4-5 #, with Paraparesisand other root signs.

Mention Initial Mainstay medical therapy andthe drug dosage and scheduleMention Initial Mainstay medical therapy andthe drug dosage and schedule

Mention 10 common side effects of the samedrug class

IV Methylprednisolone sodium succinate, hasbeen shown to improve neurologic outcome upto one year post-injury if administered withineight hours of injury and in a dose regimen of:

Bolus 30mg/kg over 15 minutes, withBolus 30mg/kg over 15 minutes, withmaintenance infusion of 5.4 mg/kg per hourinfused for 23 hours

Mnemonic: AM CUSHINGOID

Acne,Myopathy (prox) / muscle wasting (prox)Cushingoid / Cataract,Ulcers,Ulcers,Striae, Skin thin (bruising),Hypertension / Hairy,Infection,Glycosuria,Obesity / Osteoporosis / Oedema,Immunosuppression / Insomnia,Depression

A 4 yr. old girl from Mumbai, 12 kg. had feverwith chills since 3 days, Her reports show Hb.Of 9 gm%, platelet count of 40,000 / cumm.Peripheral smear shows shizonts of Pl.Falcifarum, P.I. of 3 %. Her hemodynamic &Falcifarum, P.I. of 3 %. Her hemodynamic &resp parameters are stable, Conscious

Mention type of malaria according to WHOclassification

Write 2 alternative therapies according to WHOguidelines

Uncomplicated Pl.Falciparum malaria

Classification: Uncomplicated

http://whqlibdoc.who.int/publications/2006/9241546948_eng_full.pdf

The same child redevelops fever after 12 daysof stopping your prescribed therapy…. Smearagain shows Falcifarum.

How do we treat? Write the PrescriptionHow do we treat? Write the Prescription

What is the role of Primaquine in pureFalcifarum malaria?

This 2-week-old infant, 4 kg, presented with irritabilityand emesis.

The initial heart rate was in the 300-BPM range, andthe infant exhibited grunting and tachypnea.

DiagnoseDiagnose

Write prescription for First line pharmacologicaltherapy, if it fails, what next? Mention technique ofadministration

Mention Contraindications and relativecontraindications for the use of first line therapy

Mention 2 alternative drugs

Adenosine 0.1 mg/kg (Max 6 mg) rapid bolus: Pushand Flush technique

If no responseAdenosine 0.2 mg/kg (Max 12 mg) rapid bolus

Contraindications include a deinnervated heart (eg, Contraindications include a deinnervated heart (eg,transplant) and second- or third-degree heart block.

Additionally, adenosine can worsen bronchospasm inasthmatics and increase heart block or precipitateventricular arrhythmias in those taking carbamazepine,verapamil, or digoxin.

Alternates:

RightRight AnwsersAnwsers::

Procainamide (15 mg/kg, IV, over 30–60 minor at 20–80 mg/kg/min)or at 20–80 mg/kg/min)

β blockers such as propranolol or esmolol maybe used but with caution because they mayinduce hypotension

Digoxin: but may be proarrythmic in WPW

Alternates:

WrongWrong AnwsersAnwsers::

Amiodarone should not be used in newborns duringthe first month of life because it contains thepreservative benzyl alcohol that has beenpreservative benzyl alcohol that has beenassociated with a gasping syndrome.

Verapamil should be avoided in children less than 1year of age because cardiovascular collapse anddeath can occur

Antiarrhythmics: classificationMnemonic: I to IV MBA College

Membrane Stabilisers (Na. channel blockers)

Beta Blockers Beta Blockers

Action Potential widening agents

Calcium channel blockers

IA: Disopyramide, Quinidine, Procainamide (VPC, VT,AF, PAT) IB: Lidocaine, Mexilitine (VT, VF, VPC: Only Ventricular

arrythmias) IC: Flecainide, Propafenone (Resistant ventricular arrythmias,

High incidence of Mortality in structural heart disease)

Memory joggerMemory joggerTo remember the main differences between what Class IA, Class IB,

and Class IC antiarrhythmics do, just think of their names: Class IA: Alters the myocardial cell membrane Class IB: Blocks the rapid influx of sodium ions Class IC: slows Conduction

Propranolol, Esmolol, Acebutalol (Only Atrialtachycardias: atrial flutter, atrial fibrillation,and paroxysmal atrial tachycardia)

Slow repolarization, prolong the refractory periodand duration of the action potential.

Mnemonic: BIAS Bretylium

IbutilideAmiodaroneAmiodaroneSotalol

(Amiodarone is the first-line drug of choice forventricular tachycardia and ventricular fibrillation.All are used for only Ventricular arrhythmias)

Verapamil, Diltiazem (supraventriculararrhythmias with a rapid ventricular response(rapid heart rate in which the rhythmoriginates above the ventricles)

Some calcium channel blockers (diltiazem and Some calcium channel blockers (diltiazem andverapamil) reduce the heart rate by slowingconduction through the SA and AV nodes.

Adenosine is an injectable antiarrhythmicindicated for acute treatment of PSVT, esp. re-enterant tachycardias involving AV node.

Adenosine depresses the pacemaker activity of theSA node, reducing the heart rate and the ability ofSA node, reducing the heart rate and the ability ofthe AV node to conduct impulses from the atria tothe ventricles.

Trivia: Neonates on caffeine and heavy coffeedrinkers require higher doses, as caffeineantagonizes Adenosine.

This 7 year old girl, 20 kg, operated withpalliative Bidirectional Glenn shunt for aDORV needs to undergo a Upper GI scopy forpersistent vomiting.

What advise will you give? She is not allergic topenicillin, but cannot take orally

If she was to undergo Dental extraction insteadof GI scopy, would your advise change? Whatwould it be?

If Hypothetically the said patient had anunrepaired swiss cheese ventricular septaldefect instead of the DORV, and requireddental extraction, what would you advise?

Newer Antifungals-Caspofungin

Newer antibiotics: Tigicycline, Doripenam,Etrapenam, Daptomycin, colistin

Hemodynamic drugs..Must know Hemodynamic drugs..Must know

Newer Oral chelators: Defasirox (Exjade /Asundra)

Monoclonal antibodies: Rituximab,Ofatumumab etc.

HIV therapy

Anti tubercular treatment guidelines-MDR-TB Anti tubercular treatment guidelines-MDR-TB

ALL / Lymphoma protocols

I.V. Immunoglobulin

N-Acetylcystine PO

Loading dose: 140 mg/kg PO onceMaintenance dosage (start 4 h after loading dose): 70 mg/kg PO q4h for 17 doses; total18 doses administered equaling 1330 mg/kg over 72 hIV (patients >40 kg)Acute (8-10 h after ingestion)Loading dose: 150 mg/kg IV infused over 1 h; dilute in 250 mL D5WFirst maintenance dose: 50 mg/kg IV infused over 4 h; dilute in 500 mL D5WSecond maintenance dose: 100 mg/kg IV infused over 16 h; dilute in 1000 mL D5WSecond maintenance dose: 100 mg/kg IV infused over 16 h; dilute in 1000 mL D5WEach infusion immediately follows the previous; total treatment time 21 hLate presenting or chronic (>10 h after ingestion)Loading dose: 140 mg/kg IV infused over 1 h; dilute in 500 mL D5WMaintenance doses: 70 mg/kg IV q4h for at least 12 doses; dilute each dose in 250 mL ofD5W and infuse over minimum 1 h; total treatment time 48 hDecrease total volume of D5W if fluid restriction required

Atropine (Isopto, Atropair) Initiated in patients with OP toxicity who present with muscarinic

symptoms.The endpoint for atropinization is dried pulmonary secretions andadequate oxygenation. Tachycardia and mydriasis must not be used tolimit or to stop subsequent doses of atropine.0.05 mg/kg IV, repeat q1-5min prn for control of airway secretionsStrongly consider doubling each subsequent dose to rapidly stabilizeStrongly consider doubling each subsequent dose to rapidly stabilizepatients with severe respiratory distress

PAM (Pralidoxime)20-40 mg/kg in 100 mL isotonic sodium chloride soln/D5W IV over 15-30

min; repeat in 1-2 h if muscle weakness not relieved; repeat q10-12h prnto relieve cholinergic symptomsOther dosing regimens have been used, including continuous drip; startwith bolus of 25-50 mg/kg (up to 2 g); then 10-20 mg/kg/h (up to 500mg)