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Apex- Peds Flashcards

1
Q

Compared to epiglottitis, which findings are MORE likely to occur with laryngotracheobronchitis? (select 3)

-age < 2yo usually affected
-high fver
-tripod position
-steeple sign
-onset 24- 72hrs
-more likely to require anesthesia for urgent airway control

A
  • age < 2
  • onset 24-72hrs
  • steeple sign
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2
Q

Generally speaking, what is usually bacterial vs viral:

epiglottitis (supraglottisis) or laryngotracheobronchitis (croup)

A

Epiglottis - bacterial (worse)
laryngotracheobronchitis - viral (usually)

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3
Q

Age affected of epiglottitis (supraglottis) vs laryngotracheobronchitis (croup)

A

epi = 2-6
laryngotracheobronchtiis (croup) < 2yo

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4
Q

onset of epiglottitis vs laryngotracheobronchitis

A

epi < 24hrs - rapid (bacterial)
laryngotracheobronchitis - gradual (24-72hr) (viral)

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5
Q

region affected in epiglottitis vs laryngotracheobronchitis

A

epiglottitis - supraglottic structures (above the cords- epiglottis, vallecula, aretenoids, aryepiglottic folds)

croup - laryngeal structures below the vocal cords

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6
Q

What is Thumb’s sign indicitative of?

what kind of xray?

A

swollen epiglottis (epiglottitis/supraglottitis)

lateral xray

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7
Q

What is Steeple sign indicitave of?

what kind of xray?

A

subglottic narrowing seen in laryngotracheobronchitis (croup)

frontal xray

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8
Q

T/F - tripod position helps breathing with croup

A

false - epiglottitis

maybe changes upper airway resistance? idk
think epiglottitis is 2-6yo - they are the ones who can prob assume this position anyway

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9
Q

Which one has a high grade vs low grade fever

epiglottitis vs croup

A

high grade - epi (bacterial, fast onset, worse)

low grade - croup (more gradual onset, younger)

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10
Q

What are the 4 D’s apart of ?

A

Epiglottis

Drooling
Dyspnea
Dysphonia
Dysphagia

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11
Q

clinical presentation of croup (5)

A

Low-grade fever
Inspiratory stidor
Vocal hoarseness
Barking cough
Rectractions - suprasternal, substernal, intercostal

LIVBR

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12
Q

Treatment for epiglottitis

vs treatment for croup

A

o2
urgent airway management
ENT surgeon must be present
-tracheal lintubation vs tracheostomy
-induction with spontaenous RR –> CPAP 10-15cm H20 prevents airway collapse
-abx and postop ICU care

humidified o2
racemic epi
corticosteroids
IVF
-intubation rarely required

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13
Q

When diluted into 2.5mL of 0.9% sodium chloride, what is the MOST appropriate dose of racemic epi to administer to a 30kg child with post-intubation croup?

A. 0.5mL of a 0.25% soluation
B. 0.5 mL of a 2.25% soluation
C. 5mL of a 0.25% soluation
D. 5mL of a 2.25% soluation

A

B. 0.5ml of a 2.25% solution

0-20kg = 0.25mLs
20-40kg = 0.5mL
>40kg = 0.75mL

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14
Q

Airleak should be less than what to decrease risk of postintubation laryngeal edema

A

<25cm H20

(tracheal perfusion pressure is 25cm h20, any pressure greater than this reduces tracheal perfusion > edema > reduced supglottic airway diameter > increased wob)

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15
Q

Most common risk factor for postintubation laryngeal edema

A

using too large of an ETT

maybe this is why matt always uses 7.5 for guys

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16
Q

Why do u want to be careful not to use too big of an ett?

A

post-intubation laryngeal edema

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17
Q

What 5 things can increase the risk for postintubation laryngeal edema?

A

-using ETT thats too big (most common)
-cuff pressure to ohigh
-trauma from multiple attempts
-prolonged intubation
-age <4 (more common in small kids)

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18
Q

someone has postintubation larygneal edema- now what?

A

cool and humidified o2
dexamethasone
and racemic epi (weight dependent)

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19
Q

s/s of post intubation croup

when does it typically occur?

A

hoarseness
barky cough
stridor

30-60 mins following extubation

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20
Q

T/F- trisomy 21 increase risk of post intubation croup

A

true

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21
Q

How many mLs of what % Racemic epi solution for:

0-20kg
20-40kg
> 40kg

what are you diluting it with and how much?

A

2.25% racemic epi

0-20kg: 0.25mL
20-40kg: 0.5mL
>40kg: 0.75mL

dilute with 2.5mL of NSS (each dose)

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22
Q

How much decadron would you give for post-intubation croup

how long does it take to achieve the max effect?

A

0.25-0.5mg/kg IV

4-6hrs

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23
Q

what is heliox?

how does it work?

when would you use it?

A

mixture of helium and o2

improves laminar airflow by reducing reynolds number

croup

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24
Q

t/f: antibiotics are indicated for post-intubation croup

A

false

unlike laryngotracheobronchitis (infecious coup); post intubation croup is not infectious

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25
how long should patients be aboverved for after racemic epi tx is complete?
minimum of 4 hours
26
What age is postintubation laryngeal edema most often seen?
<4yo
27
How long do most clinicians postpone a procedure for kids with an active URI | why
2-4 weeks after onset of symptoms | active or recent hx increases risk of pulm complications
28
When would you cancel a snotty kid? (6)
1. purulent nasal discharge 2. temp > 38 3. lethargy 4. persistent cough 5. poor appetite 6. wheezing and rales that don't clear with cough
29
if you have to use an ETT in a kid with a recent URI, how should you proceed?
use a smaller size than normal
30
t/f - pretreating a kid with a recent URI with inhaled bronchodilator or glyco does NOT provide a clear benefit
True
31
What is the best volatile agent for a kid with a recent URI?
SEVO
32
How long can the risk of pulmonary complications persist for after the onset of URI symptoms
6-8 weeks but clinicans will wait 2-4
33
T/F- a snotty kid that was a previous preemie is reason enough to cancel an elective case
true | or <1yo
34
Mechanical irritation (ETT use) increases the risk of bronchospasm by how much in snotty kids?
10 fold
35
snotty kids that are cleared for surgery- considerations | 5
use least irritating airway if ett is needed, downsize decadron 0.25-0.5mg/kg to reduce risk of post-intubation croup ensure deep lane of anesthesia before instrumenting airway sevo
36
a 3yo kid aspirated a peanut and comes in for rigid bronchoscopy. What is the MOST important anesthetic consideration for this patient? A. inhalational induction B. observing NPO guidelines C. Positive pressure ventilation D. Rocuronium
A. inhalational induction ## Footnote *goals = prevening complete airway obstruction and preventing it from moving distally in the airway (which PPV would do)
37
Classic triad of foreign body aspiration
cough wheezing decreased breath sounds on affected side (usually right)
38
in kids with a foreign body aspiration, what would stridor vs wheezing indicate?
stridor = supraglottic obstruction wheezing = subglottic obstruction
39
gold standard procedure to retrieve foreign body from the airway?
rigid bronchoscopy
40
Best maintenance technique for foreign body aspiration removal with rigid bronch | anesthesia
TIVA
41
"What can happen during rigid bronchoscopy that you need to be aware of" (4)
1. laryngospasm 2. bradycardia during scope insertion 3. PTX 4. post-intubation croup
42
What should you do after rigid bronch for foreign body removal if the patient doesnt immediately improve afterward?
observe- can be normal due to residual lung inflammation
43
Why is it best to maintain spontaneous ventilation throughout a rigid bronchoscopy?
bc it maintains laminar flow and reduces risk of foriegn body moving distally
44
can the anesthesia circuit be connected to the port on the rigid bronchoscope to deliver o2 and voliatle agents during the procedure?
yes...you can also deliver breaths if needed ## Footnote -
45
Induction, maintenance main goals with rigid bronchosocopy for foreign body remvoal?
induction- sevo with spontaneous respirations matinenance- avoid PPV, TIVA (gases leak out around the rigid bronch) *no coughing or bucking - object can move distally
46
If using sevo during a rigid bronchoscope and it's leaking out around the scope, it can dilute the concentration of volatile anesthetic, making it difficult to maintain a sufficent level of anesthesia. How can you compensate for this leak?
by increases FGF and vaporizer output (although TIVA is prob best)
47
What congenital condition is associated with macroglossia? A. Glucose-6 dehydrogenase deficiency B. Klippel-Feil C. Treacher Collins D. Trisomy 21 | probelm?
D. | risk of upper airway obstruction
47
What congenital condition is associated with macroglossia? A. Glucose-6 dehydrogenase deficiency B. Klippel-Feil C. Treacher Collins D. Trisomy 21 | probelm?
D. | risk of upper airway obstruction
48
Conditions with large tongues | mneumonic
Beckwith Syndrome Trisomy 21 | "Big Tongue"
49
Conditions with small/underdeveloped mandible | mneumonic ## Footnote another name for small/underdeveloped mandible
Pierre Robin Goldenhar Treacher Collins Cri du Chat | Please Get That Chin ## Footnote MicroGnathia
50
What is micrognathia?
a small/underdeveloped chin ## Footnote please get that chin pierre, golden, treacher, cri du chat
51
C-Spine Anomaly conditions | mneumonic
Klippel Feil Treacher Collins Golden Har | kids try gold (to fix thier spines)
52
4 anesthetic considrations for cleft lip and palate
1. airway obstruction 2. difficult laryngoscopy 3. difficult mask ventilation 4. aspiration
53
risk with the dingman-dott mouth retractor
it can reduce venous drainage and cause tongue engorgement, increasing the risk of post-extubation airway obstruction
54
What condition
Pierre Robin ## Footnote 1. small/underdeveloped mandible 2. a tongue that falls back and downward (glossoptosis) 3. cleft palate 4. neonates often require intubation
55
Which condition is associated with a cleft palate
pierre robin
56
what is glossoptosis | what condition is it associated with
a tongue that falls back and downward | pierre robin
57
t/f- kids with klippel-fiel often require intubation as neonates
false - pierre robin
58
what condition is associated with choanal atresia and what is that?
treacher collins ## Footnote nasal airway blocked by tissue
59
what condition is associated with a small mouth? (2)
treacher collins & downs
60
what condition? ## Footnote 4 things associated with it
Treacher collins ## Footnote 1. small mouth 2. small/under developed manidble 3. (small) nasal passages - blocked by tissue (choanal atresia) 4. ocular and auricular anomalies
61
which condition is associated with ocular and auricular anomalies
treacher collins
62
4 major things associated with trisomy 21
1. small mouth 2. large tongue 3. atlantoaxial instability 4. small subglottic diameter (subglottic stenosis)
63
What is klippel-fiel?
a congenital fusion of the cervical vertebrae > neck rigidity
64
2 big things with goldenhar
1. small/underdeveloped mandible (Please Get That Chin) 2. C-Spine abnormality (Kids Try Gold)
65
3 things associated with cri du chat
1. Small/underdeveloped mandible (Please Get That Chin) 2. Laryngomalcia 3. Stridor
66
T/F- Cleft lip and palate are commonly asssociated with other genetic disorders
true
67
when is cleft lip repair done vs cleft palate ?
cleft lip - 1 month cleft palate - 1 year
68
What is the MOST common cardaic anamaly associated with Down syndrome? A. AV septal defect B. 1st degree heart block C. Bicuspid aortic valve D. Single ventricle
A. ASD
69
What % of infants with down syndrome have co-exisisting cardiac disease? ## Footnote most common vs 2nd most common
50% ## Footnote most common = atrioventricular septal defect (AV-SD) 2nd most common = ventricular septal defect (VSD)
70
T/F- Trisomy 21 is the most common chromosomal disorder
True
71
Why are pt's with Down syndrome at increased risk for difficult ventilation AND intubation?
small mouth, big tongue high, arched palate midface hypoplasia (difficult seal) A-O instability (difficult sniffing position) subglottic stenosis (difficult intubation) OSA (difficult BMV)
72
other than difficult ventilation and intubation risk, what 3 other concerns are you on the lookout for ? (Down’s syndrome)
1. co-exisiting congenital heart disease 2. low muscle tone and GERD (aspiration) 3. intellectual disability
73
Our genetic makeup consists of how many pairs of chromosomes? | how is downs different?
23 pairs | additional 3rd copy of chromosome 21 (TRIsomy 21) ## Footnote 23 birthday 23 generations of bronchioles 23 pairs of chromosomes 2-3 months = dilutional anemia 2-3 months = highest mac 2-3cm of water mandatory minimum PEEP for standing bellows vent 2.2mm = smallest fiberoptic bronchoscope & can be used in ett as small as 3.0
74
T/F- older moms are more likely to give birth to a child with Down Syndrome
True
75
T/F- Down syndrome affects nearly every organ system
True
76
T/F- Downs kids hsould have a preop c-spine xray before anesthesia
True! ## Footnote atlantoaxial instability - avoid neck flexion during laryngoscopy
77
why should you use a smaller ETT in downs kids??
subglottic stenosis- risk of postintubation croup
78
What is endocardial cushion defect and who might have it
AV septal defect - downs kids
79
Caution with downs kids and sevo induction
bradycardia is common - careflly stair step up sevo concentration to avoid profound bradycardia ## Footnote *tx with anticholinergics
80
VACTERL association
Vertebral defects Anus imperforated Cardiac anomalies TEF Esophageal atresia Renal dysplasia Limb anomalies
81
CHARGE association
Colomba (hole in eye structure) Heart defects Atresia (ChoAnal) Restriction of growth and development Genitourinary problems Ear anomilies
82
CATCH 22 | AKA
Cardiac defects Abnormal face Thymic hypoplasia Cleft palate Hypocalcemia 22q11.2 gene deletion (cause of the syndrome) | DiGeorge Syndrome
83
What is DiGeorge Syndome caused by? | AKA?
deletion of gene 22q11.2 | CATCH22 ## Footnote Cardiac defects Abnormal face Thymic hypoplasia Cleft palate Hypocalcemia 22q11.2 gene depletion
84
3 things to avoid in a kid with DiGeorge syndrome
hyperventilation, albumin and citrated blood products | all of these lower ionized calcium concentrations in blood ## Footnote these kids already have hypocalcemia at baseline
85
3 key facts about DiGeorge Syndrome
1. low calcium- avoid hyperventilation, albumin, and citrated blood 2. high risk for infection if thymus is absent > tx w thymus trnasplant are mature T cell infusion 3. need leukocyte-depleted irradiated blood
86
What is the MOSt common coagulation disorder in children undergoing adenotonsillectomy? A. Hemophilia A B. Heparin-induced thrombocytopenia C. Sickle cell disease D. von Willebrand disease
D. Von Willebrand Disease
87
Your doing tonsils and adenoids on a kids and you see DDAVP is ordered... what are your thoughts? | Risks with DDAVP ## Footnote postop risks
kid probably has von willebrand disease (most common coag disorder in these patients ) | risk of hyponatremia- decrease IVF maintenance to 1/2 calculated rate ## Footnote postop bleeding, montior sodium
88
2 indications for T&A's
recurrent infections or nocturnal upper airway obstruction
89
What is the most common cause of OSA in kids
adenotonsillar hypertrophy
90
How much decadron to give to T&A patients and why?
1mg/kg up to 25mg ## Footnote reduce postop airway swelling, pain, and PONV analgesia via inhibition of periphearl phospholiapse > decreases pain reducing substances from COX and lipoxygenase pathways
91
How do you decrease the risk of airway fire with T&A?
low fio2 (<40%) and avoid nitrous (supports combustion)
92
kids with OSA undergoing adenotonsillectomy need to be admitted to the hospital for how long and why?
23 hours to be monitored for airway obstruction
93
key anesthetic risks with postop tonsil bleeding
hypovolemia and aspiration *volume resusitation and RSI ## Footnote *Surgical emergency
94
T/F- codeine is the drug of choice for postop pain in kids after T&A's
false- risk of resp depression (FDA warning) ## Footnote codeine = prodrug > body metabolizes it to morphine, kids are fast metabolizers
95
how can you assess for VWD in kids presenting for T&A?
easy/frequent bruising nose bleeds family history of bleeding disorders
96
How should you preoxygenate the bleeding tonsil patient?
left-lateral, head down position (helps drain blood from airway)
97
What should you do after securing the airway of a bleeding tonsil?
pas OGT to decompress the stomach
98
When do most post-tonsillectomy bleeds occur?
wtihin the first 6 hours of surgery (75%)
99
A child with which condition is MOST likely to develop QT prolongation after blood products? A. DigEorge Syndrome B. CHARGE association C. VACTERL association D. Trisomy 21
A. DiGeorge Syndrome ## Footnote these kids have hypocalcemia at baseline and citrated blood products reduce calcium further (bind it) , low caclium > prolonged QT
100
What is the MOST common indication for liver transplantation in kids < 2yo: A. Alpha-1 antitrypsin deficiency B. Biliary atresia C. Cystic fibrosis D. Alagille syndrome
B. Billiary atresia
101
Most common electrylyte abnormaility in the neonate: A. Hypocalcemia B. Hypoglycemia C. Hypokalemia D. Hyponatremia
B. hypoglycemia

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