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APLS > Circulation, Seizures and Coma > Flashcards

Circulation, Seizures and Coma Flashcards

1
Q

What are the 3 stages of shock

A

Compensated
Decompensated
Irreversible

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2
Q

Features of compensated shock?

A

Cold peripheries
tachycardia
elevated diastolic pressure
Agitation
reduced UO

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3
Q

Signs of uncompensated shock

A

Prolonged CRT
Cool peripheries
Low BP
Acidotic breathing
reduced UO

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4
Q

Main classes of shock

A

Hypovolaemia - including peritonitis and intussuception
Distributive - eg septic/anaphylaxis
Cardiogenic -
Obstructive -

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5
Q

Where does adrenaline come in during ABCDE assessment of anaphylaxis?

A

In A if signs of obstruction

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6
Q

What are the man ductus dependent syndromes in neonates? Treatment?

A
  1. duct dependent pulmonary circulation (critical pulmonary stenosis, pulmonary atresia, tricuspid atresia)
    -present in the first few days of life with increasing cyanosis unresponsive to supplemental oxygen and signs of severe hypoxaemia with little respiratory distress before collapsing with cardiogenic shock.
  2. Duct dependent systemic circulation (transposition of the great vessels, aortic stenosis, hypoplastic left heart, coarctation of the aorta)
    -present in the first few days of life with an inability to feed, breathlessness, a grey appearance, and collapse with poor peripheral circulation and cardiogenic shock.

1) Assess ABC

2) Judicious use of oxygen

3) Intravenous prostaglandin E1

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7
Q

Name 4 causes of seizures in children

A

1) Febrile seizures

2) Epilepsy

3) Meningitis

4) Raised ICP

5) Hypoglycaemia

6) Electrolyte abnormalities eg hyponatremia

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8
Q

Seizure APLS algorithm ? Doses?

A

5 min - Midaz 0.15mg/kg (max 10mg)

5 min - Midaz 0.15mg/kg (max 10mg)

5 min - Levetiracetam 40mg/kg (max 3g) over 5 mins
OR Phenytoin 20mg/kg over 20 mins
+ICU / anaesthetics

5 min after infusion - the other one from above
OR phenobarbitone

5 min after infusion
RSI

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9
Q

What are the reversible causes of status in a kid? Emergency management of these

A

Systemic
-Hyponatraemia (<125mmol) - 3-5mls/kg of 3% NaCl
-Hypoglycaemia - 2-3mg/kg 10% glucose
-Hypertension -

Intracranial
-Infection - Cef + acyclovir
-Bleed
-Raised ICP

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10
Q

When would you not follow APLS algorithm for seizures

A

Compromised airway not responding to basic manoeuvres

Shock unresponsive to fluid resus

Raised ICP / trauma

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11
Q

Bar electrolytes and glucose what blood test should you send off in status

A

Ammonia
FBC

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12
Q

Buccal/nasal midaz and rectal diazapam dose in status

A

Buccal/nasal midaz - 0.3mg/kg (max 10mg)

Rectal diazepam - 0.5mg/kg

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13
Q

Kid with status on keppra usually at home. What dose of keppra can you give?

A

The full 40 mg/kg dose can be given even if the child is on regular maintenance levetiracetam.

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14
Q

Phenytoin dose in status and speed of infusion?

A

It is given at a dose of 20mg/kg infused at a rate of no faster than 1mg/kg/minute (20 minutes)

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15
Q

Phenobarbitone dose? More commonly used in?

A

Phenobarbitone is a second line anticonvulsant administered intravenously at a dose of 20 mg/kg.
It is more commonly used in neonates and infants.

Being a barbiturate it may cause respiratory depression and hypotension.

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16
Q

GCS score for children <4

A
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17
Q

GCS for kids 4-15

A

Same as adults

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18
Q

What is decorticate posturing.

A

flexed upper limbs and extended lower limbs.

Decorticate posturing indicates an insult to the brain in the areas of the cerebral hemispheres, internal capsule and thalamus

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19
Q

What is decerebrate posturing

A

extended upper limbs and extended lower limbs. It is sometimes referred to as extensor posturing.

Decerebrate posturing indicates brain stem pathology.

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20
Q

What are you worried about if a kid goes from decorticate to decerebrate posturing?

A

May indicate brain stem herniation.

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21
Q

Low GCS with
Small reactive pupils?
Pinpoint?
Fixed midsize?
Fixed dilated?
Unilateral dilated?

A
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22
Q

Emergency management of meningitis

A

Assess and manage ABCDE

IV antibiotics such as third generation cephalosporins

IV acyclovir if encephalitis is a possibility

Correct hypoglycaemia and any other electrolyte abnormalities

Consider steroids

23
Q

What are the 2 main clinical syndromes that occur as ICP rises

A

Central syndrome - where the whole brain is pressed towards the foramen magnum and the cerebellar tonsils herniate through it. This is known as “coming”

Uncal syndrome - where the uncus is forced through the tentorial opening and compressed against the free edge of the tentorium. This leads to third nerve compression and an ipsilateral dilated pupil.

24
Q

Emergency management of raised ICP

A

Intubation and ventilation to maintain a low normal C02 level

20 degrees head up position

Intravenous mannitol or hypertonic saline

Dexamethasone

25
Q

Define sepsis

A

Sepsis is defined as proven or suspected infection in the presence of an abnormal heart rate, respiratory rate, temperature or white cell count. This is termed a systemic inflammatory response.

An alternative definition is: sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.

26
Q

Define septic shock

A

Septic shock is present when sepsis is accompanied by cardiovascular dysfunction. Hypotension is a late sign.

27
Q

If there are signs of shock (+/- lactate is more than 2 mmol/l) and there are no signs of fluid overload treatment?

A

give 10 ml/kg of isotonic crystalloid. Assess the haemodynamic response at the bedside and repeat if there is evidence of improvement but still signs of shock.

Inotropes should be considered if no improvement after 20 ml/kg of fluid boluses.

28
Q

Sepsis without access to pressors?

A

Surviving Sepsis campaign guidelines only recommend fluid boluses if there is evidence of both impaired perfusion and hypotension. In the absence of hypotension, maintenance fluid with vasoactive support (if available) is recommended.

[The FEAST (Fluid Expansion As Supportive Therapy) study was published in 2011 and showed that in a resource-limited setting in Africa, without access to intensive care, children with severe febrile illnesses and evidence of impaired perfusion who were treated with fluid boluses had a significantly increased mortality compared with controls.]

29
Q

Sepsis in a neonate Abx choice?

A

CefotaximeIV 50 mg/kg

and
Amoxicillin

30
Q

Antibiotic choice in septic kids >1m months

A

Cefotaxime IV 50 mg/kg
or
Ceftriaxone IV 50-100 mg/kg (4 gm MAX)

plus
Flucloxacillin IV 50 mg/kg

31
Q

Cause of maculopapular rash in staph toxic shock

A

The rash is caused by a superantigen toxin (TSST-1) that results in polyclonal T cell activation.

32
Q

Urine sample from a neonate in septic screen

A

A supra pubic aspirate of urine is a rapid, accurate and reliable way of obtaining an uncontaminated sample of urine from a neonate.

33
Q

6m with septic shock, hypotension, fever and hypoglycaemia first fluid choice

A

2 mls/kg of 10% dextrose IV for hypoglycaemia first

34
Q

Name 3 causes of decreased fluid intake in kids

A

Nausea and or vomiting

Painful oral lesions like primary herpes

Reduced consciousness

Sepsis

35
Q

Name 3 causes of increased fluid intake by kids

A

Fever

Vomiting

Diarrhoea

Increased urine output, as in diabetes mellitus or insipidus

Third space losses

36
Q

Gold standard for defining dehydration status in kids

A

Weight loss

37
Q

Can you think of 5 signs on exam which would indicate >10% volume fluid loss

A

dehydration and no shock can be assumed to be 5-10% dehydrated; if shock is present, then greater than 10% dehydration has occurred.

38
Q

When would you use NG rehydration? IV?

A

<3 and not tolerating oral

> 3 and not tolerating oral, or <3 failed on NG

39
Q

Fluid of choice for kids resus

A

20mg/kg 0.9% Nacl + 5% dextrose
Hartmans

40
Q

How to calculate maintenance fluids in kids

A

First 10kg - 100ml/kg
+10-20kg - 50ml/kg
>20kg - 20ml/kg

eg 30kg child = 1000+500+200

41
Q

How to calculate deficit volume in kids

A

% dehydration x weight x 10

42
Q

When might you be more cautious using lots of fluids in septic kids

A

Acute CNS conditions eg meningitis
Pulmonary conditions eg pneumonia, bronchiolitis

Both may cause ADH secretion

43
Q

Maintenence fluid choice in kids

A

IV maintenance is sodium chloride 0.9% with glucose 5%.

Alternative maintenance fluid options include:

Plasma-Lyte 148 with glucose 5% (contains 5 mmol/L of potassium)
Hartmann’s with glucose 5%

44
Q

How fast do you want to correct severe hypoNa

A

no more than 8 mmol per 24 hrs

45
Q

Management of hyperkalemia algorithm? Doses?

A

Arrhythmia-> 0.1mmol/kg (0.5mls/kg 10%) Calcium

Salbutamol - 5-10mg neb

If still high:
pH < 7.35 - give bicarbonate 1mmol/kg (1ml/kg of 8.4%)
pH > 7.35 - insulin 0.05u/kg/hr + dextrose 5ml/kg 10%

Once falling
Resonium 1g/kg

46
Q

tachycardia, prolonged capillary refill time, dry mucus membranes how dehydrated?

A

> 10%

47
Q

Seizing with hypoNa fluid

A

3 mls/kg of 3% saline over 15-30 minutes will generally raise the sodium level enough (2-3 mmol/l)

48
Q

HyperNa eg 165 + dehydrated child fluid choice? Na aim over 24 hrs?

A

Plasma-Lyte 148 or N.Saline (+/- 5% dextrose) to manage hypernatremic dehydration

Sodium levels should only be changed cautiously by 8-12 mmol/l in 24 hrs.
[Too rapid correction of hypernatraemia may lead to cerebral oedema and convulsions]

49
Q

HyperK and acidotic rx?

A

Sodium bicarbonate (1mmol/kg IV)

Correction of the acidosis will shift potassium back into the cells

50
Q

Fluid resus before pressors in hypovolemic shock

A

40mls/kg

51
Q
A
52
Q

Coma algorithm

A
53
Q

Why dex in meningitis

A

Reduces long term learning development
Less hearing loss

54
Q

Where do you check pre ductal sats / BP

A

Right arm

APLS (4 decks)

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