Critical Care Flashcards
(188 cards)
1
Q
OSCE approach to the acutely ill child
A
- Personal Protective Equipment and wash hands
- Name, identify team
- If TRAUMA, C-spine stabilization
- Request Monitors
- Apply Oxygen
- Request IV access
MOST IMPORTANT IF ALONE
* ABCDs with FULL vitals
* Glucose check
* Call for help (nurses, RTs, consultants)
- Advance Directives (consider in chronic patient)?
- Reassess ABCD and vitals
*Patient disposition - need to call tertiary pediatric hospital or PICU?
2
Q
Steps of ABCDs
A
Airway
- Patent (stridor, vomiting, bloody?)
- Midline position
- Protected (cranial nerve 9 or 10 fxn?)
Breathing
- Sats, RR
- WOB
- Breathing pattern
- Auscultation
- Gas (CO2 clearance)
Circulation
- HR, BP, Temp
- Pulses central and peripheral
- Capillary refill
- Rhythm (*often overlooked!)
- Heart sounds
- End organ perfusion: mentation, urine output
- Labs: gas & lactate
Disability
- GCS (level of consciousness)
- Pupils
- Major neurological focal deficits
- Blood Sugar
3
Q
- 2y to ED w/ 2d cough, fever, and stridor today
- Prev healthy, immunized
- In ED: PO dexamethasone (4h ago), epi neb Q1h minimal effect
- Vitals: HR 168, BP 108/60, RR 42, sat 87% w/ NRB, T 38.2 C
- Severe indrawing/stridor awake, improves slightly when calmed
What is the most appropriate next step?
A. Administer IV dexamethasone
B. Consult anesthesia for intubation
C. Administer vancomycin and oseltamivir
D. Administer lorazepam
A
consult anesthesia for intubation - this is an upper airway obstruction that has lead to hypoxia, high risk for respiratory failure
4
Q
- 6y F, 25kg to ED with status epilepticus
- Apneic post-treatment, no obstruction, easy to ventilate
- Requires intubation
What is the most appropriate endotracheal tube size?
A. 4.0 cuffed ETT
B. 4.5 cuffed ETT
C. 5.0 cuffed ETT
D. 5.5 cuffed ETT
A
5.0 cuffed
Cole’s Formula:
Cuffed ETT diameter = [(age in yrs)/4] + 3.5
(uncuffed is age in yrs/4 +4)
6/4 = 1.5
1.5 + 3.5 = 5
Memory aid: uncuffed is rough so +4
Cuffed is fancy like cufflinks so 3.5
5
Q
Indications for Intubation?
A
- Unprotected/Obstructed Airway (GCS =< 8, facial trauma, etc)
- Impending Resp Failure (Refractory hypoxia/CO2 retention, severe WOB)
- Specific high-risk situations (Severe TBI, inhalation injury)
- Facilitate long transport or procedures
6
Q
Airway Assessment prior to intubation?
A
Previous intubations?
Stridor or noisy breathing?
Neck ROM?
Facial deformities or known airway anomalies?
Related imaging (eg mediastinal mass)?
7
Q
Reasons to call anesthesia for intubation?
A
– Upper airway obstruction (especially glottic or sub-glottic… think high-pitched stridor)
– Mediastinal mass
– Known/anticipated difficult airway
8
Q
Approach to decomposition post-intubation?
A
DOPE
Displacement
Obstruction
Pneumothorax
Equipment Failure
9
Q
What is the definition of respiratory failure?
A
Failure of:
* Ventilation (PaCO2 > 50mmHg or > 20 above baseline)
* Oxygenation (PaO2 < 60)
* Gas Exchange
* Airway Protection
10
Q
what does resp failure look like clinically?
A
- Increased, Decreased or No Respiratory Effort
- Tachypnea & Tachycardia (Early)
- Bradypnea/Apnea and Bradycardia (Late)
- Cyanosis
- Poor distal air movement
- Depressed Mental Status
11
Q
What can we titrate to improve oxygenation?
A
FiO2
PEEP
12
Q
What can we titrate to improve CO2 clearance?
A
RR
Tidal volume
13
Q
what can we do to improve WOB in a mechanically ventilated patient?
A
Increase inspiratory pressure
Lower airway resistance (ventolin, bigger ETT)
14
Q
Causes of hypoxemic (Type 1) respiratory failure?
A
V/Q mismatch (asthma, PNA, PE); Hypoventilation (central apnea, neuromuscular weakness, hypotonia); Shunt (R to L cardiac, atelectasis); Diffusion (pulmonary fibrosis)
Ventilation/Perfusion (V/Q) mismatch - MOST COMMON
□ Asthma - inflamed, bronchospasm + mucous plugging -> block gas exchange
□ Ventolin in excess
□ Pneumonia - parenchymal loss
□ Pulmonary edema
□ ARDS
□ Low cardiac output - decreased lung perfusion
□ Endobronchial intubation - only one lung being ventilated
□ Pulmonary embolism - only some areas of lung receive blood
Alveolar Hypoventilation increase CO2
□ Central apnea or periodic breathing
□ Neuromuscular conditions
□ Chest wall disease
□ Hypotonia
□ Asthma or airflow obstruction
Shunt does not respond to oxygenation
□ Mixing of oxy and deoxy blood (arterio-venous fistula (AVM))
□ Cardiac (R->L lesion bypassing the lungs) - ASD/VSD
□ Atelectasis - no ventilation given alveolar collapse
□ Severe pneumonia
Impaired O2 delivery
□ Carbon monoxide or cyanide poisoning
Decr inspired O2
□ higher altitude means lower partial pressure of inspired O2
Impaired diffusion - usually coexists with V/Q mismatch, and on its own is a rare cause of hypoxemia in children
□ Interstitial lung disease - inflammation and fibrosis
□ Pulmonary artery hypertension
15
Q
Causes of hypercapneic (Type 2) respiratory failure?
A
Pulmonary (Can’t Breathe):
- PNA, asthma, CF
- obesity, kyphoscoliosis, neuropathies, myopathies
Central (Won’t Breathe): decreased respiratory drive
- metabolic alkalosis
- congenital central hypoventilation syndrome
- CNS infection, sedation, injury
Increased CO2 Production
- fever, sepsis, burns
16
Q
what is the most common cause of hypoxemic respiratory failure?
A
Ventilation/Perfusion (V/Q) mismatch - MOST COMMON
□ Asthma - inflamed, bronchospasm + mucous plugging -> block gas exchange
□ Ventolin in excess
□ Pneumonia - parenchymal loss
□ Pulmonary edema
□ ARDS
□ Low cardiac output - decreased lung perfusion
□ Endobronchial intubation - only one lung being ventilated
□ Pulmonary embolism - only some areas of lung receive blood
17
Q
which causes of hypoxemic respiratory failure does not respond to oxygen?
A
Shunt does not respond to oxygenation
□ Cardiac (R->L lesion bypassing the lungs) - ASD/VSD
□ Atelectasis - no ventilation given alveolar collapse
□ Severe pneumonia
□ Mixing of oxy and deoxy blood (arterio-venous fistula (AVM))
18
Q
what is the Aa gradient?
A
How much oxygen is in the Alveoli compared to the arterial blood
A-a gradient is Alveolar to arterial oxygenation (A-a gradient = PAO2 - PaO2)
19
Q
what is the hyperoxia test? what defines a positive test?
A
obtain pre-ductal (right radial) ABG on room air
have them breathe 100% FiO2 for a few minutes then repeat ABG
Norally the PaO2 would go from 70 to super high (>300)
versus in cyanotic heart disease the FiO2 can only get up to 150
positive test for cyanotic heart disease is FiO2 <150 (memorize this number)
indicating hypoxemia is from cyanotic heart disease
20
Q
describe pulse oximetry in a patient with transposition of the great arteries (TGA)?
A
Reverse Differential Cyanosis
pre-ductal: 75%
post-ductal: 90%
21
Q
describe pulse oximetry in a patient with LV outflow obstruction?
A
Differential Cyanosis
pre-ductal 95%
post-ductal 75%
High pressure in LV <- LA <- Lungs
Thus blood shunts from R to L through the PDA (from high pressure pulmonary artery to low pressure descending aorta (aorta post-obstruction is low pressure), this deoxy blood from the right side gets pumped into circulation
22
Q
What does elevated A-a gradient mean? Which causes of hypoxemic respiratory failure have elevated A-a gradient?
A
Elevated Aa gradient - the oxygen in the Alveoli is not getting into the blood
- V/Q mismatch
- Shunting
- Diffusion limitation
23
Q
Most concerning features of impending respiratory failure?
A
- Bradypneic (slow RR in context of previously tachypneic)
- Agitation leading to Altered LOC (agitation can indicate impending code, is often treated wrongly with sedatives)
24
Q
Pediatric Risk Factors for respiratory failure (compared with adults)?
A
- Narrow airways (more prone to collapse => Croup, bronchiolitis)
○ Subglottic is narrowest part of airway - More compliant chest wall (can’t create as much negative pressure)
- More cartilage in ribs (more prone to dynamic collapse)
25
is extrathoracic airway obstruction worse during inspiration or expiration?
this is stridor, worse with inspiration
when they exhale, the airway patency is restored
vs intrathoracic (asthma), worse with exhalation because their airways collapse
26
Infant Risk Factors for respiratory failure?
* Immature CNS controllers of Respiratory Drive
* Large Tongue + Obligate Nasal Breathers
27
Common syndromes associated with macroglossia?
Trisomy 21
Beckwith-Wiedemann Syndrome
28
Name 4 signs of inhalation injury:
* face & neck burns, soot
* Singeing of eyebrows/nasal hairs
* Carbon ("Carbonaceous") deposits in the oropharynx
* Hoarseness/Stridor
* Signs of parenchymal involvement (Wheeze, ↑WOB)
29
what is the cause of altered LOC in a patient with inhalational injury (Eg from a house fire)?
Carbon monoxide or cyanide (hydrogen cyanide) poisoning
kids often run and hide when scared, so they get trapped in house fires and breathe in a lot of cyanide from items burning
30
Intubation indications for smoke inhalation injuries?
Early intubation if any of the following:
- Singed nasal hairs
- Soot in the airway
- Hoarseness
- Drooling
31
A child with burns and inhalational injury requires intubation - medication considerations for RSI?
Succinylcholine = Contraindicated for RSI in Burns
can increase risk of hyperkalmema and cardiovascular instability
32
Kid from burning house, covered in soot; sat 89%; is it?
a. Accurate
b. Overestimated
c. Underestimated
Overestimated
presume carbon monoxide (CO) poisoning in house fires
CO attaches to hemoglobin stronger than oxygen
Саrbοхуhеmoglοbin impairs release of oxygen
pulse oximetry cannot differentiate ϲаrbοхуhеmоglоbiո from oxyhemoglobin
33
presentation of carbon monoxide poisoning? What are you most worried about?
Initially headache
Dizziness, nausea
Confusion, seizure, syncope, coma
Symptoms DON'T correlate with COHb level
Dysrhythmia and cardiac arrest can happen even with <30% COHb level !!!!
34
Diagnosis of carbon monoxide poisoning?
Carboxyhemoglobin (COHb) level > 3% consistent with toxic inhalation
35
Carbon Monoxide Poisoning Management?
Remove from source and rule out smoke inhalation
Treat if COHb > 10% if 100% FiO2
Hyperbaric oxygen (best if < 6 hrs of exposure) if:
- COHb > 25% (> 20% in pregnant or child)
- Neurologic symptoms (loss of consciousness, seizure, cardiac ischemia, cerebellar deficits)
36
Burns are classified into superficial, superficial partial-thickness, deep partial-thickness and full thickness.
What are differentiating features between superficial and deep partial thickness burns?
Superficial partial thickness
- red, painful, moist, BLISTERS
Deep Partial Thickness
- pale, less tender, dry, speckled
*GRAFTING often needed*
37
Initial management of burns?
Cover with sterile bandages
Early cooling ( < 30 min) prevents further injury
Tetanus (dirty wound)
Analgesia
Remove smoldering clothing
Fluids
38
Burns are classified into superficial, superficial partial-thickness, deep partial-thickness and full thickness.
What are the layers of skin affected?
Superficial: epidermis only
superficial partial: Epidermis + 1/2 Dermis
deep partial: Epidermis + > 1/2 Dermis
full thickness: subcutaneous tissue
39
Fluid management principles in burn victims? calculate for 4kg child with 20% BSA
Parkland Formula 4mL x %TBSA
* ½ over the 1st 8 hours, ½ over the next 16 hours
* must use LACTATED RINGERS
* Add maintenance fluids on top (dextrose)
but continue to titrate to target UO 1ml/kg
be careful of wording (fluids thus add in maintenance or resuscitative fluids only?)
ex. 4 kg kid
4 ml x 20% = 80
80 / 2 = 40 ml
40/8 = 5ml/hr
maintenance fluids would be 16ml/hr
5 + 16 = 21 ml/hr
40
Complications of burns
hypoglycemia (if <20kg)
infection
41
what is the most common cause of morbidity and mortality in burn patients?
infection
42
what pathogens cause infection in burn victims and how do we prevent infection?
Early infection: Staph aureus, GAS
Late infection: Pseudomonas, Bacteroides
Daily dressing change with topical antibiotic BID until re-epithelialization
43
When do you suspect non-accidental injury (NAI) in burn victims?
> 10% BSA partial thickness
> 2 % BSA full thickness
> 1% BSA of hands/feet/face/perineum
Donut sign
Circumfrential burn
from getting dipped in hot water and kids trying to pull lets up
(BSA = body surface area)
44
Complications from high tension wire electrical injuries?
Muscle damage => Compartment syndrome, rhabdomyolysis => Acute Renal Failure (monitor UO)
CNS injury common
VF/arrest common (continuous ECG)
45
Patient presents with Entrance/exit wounds, Rhabdomyolysis and VF/arrest. What could the injury have been?
High Tension Wire Electrical injury
46
Features of injury from lightening strike?
"feathered" lightening burn
asystole
Cerebral edema (delayed), ICH, seizure
Rhabdomyolysis (overlapping feature of high tension wire injury)
47
prevention strategies for submersion injuries (aka drownings)?
4-sided self closing fence, 4 ft high
toddlers need to be within arm's length of caregiver, including in bathtub
1 adult per baby, 1 adult per 2 young children
48
management of submersion injury?
remove from water
ABCs - high flow, CPAP, early intubation
decompress stomach after airway secured
assess for hypothermia
end organ fxn: art gas for hypoxemia, lytes, kidney fxn, glucose, ECG
ethanol level
49
Important factors favouring survival after a submersion injury?
immediate bystander CPR (best per Hamilton)
Submersion < 5 min (best per Dr. Doughty)
return of spontaneous circulation in < 10 min
Pupils equal and reactive at scene
Normal sinus rhythm at scene
50
poor prognostic factors following submersion injury?
delayed CPR
ROSC >25min
Submersion >10min
art pH <7.1 (same as severe DKA)
51
Presentation of epiglottitis?
key is sore throat/difficulty swallowing, drooling and muffled "hot potato" voice
Fever + 4 D's
Dysphagia, dysphonia, drooling, distress
*sniffing position*
52
what pathogen most often causes epiglottitis?
H flu (especially in unimmunized kids, epiglottitis is more rare since we started vaccinating against Haemophilus influenzae)
Unimmunized children: H flu (encapsulated organism)
Immunized children: non-typeable H flu; Neisseria meningitidis or strep species
53
Management of suspected epiglottitis?
hands off!!! do not look in their mouth!!!
INTUBATE immediately in children - call anesthesia/PICU/ENT
○ Using general anesthesia but not muscle relaxants
○ will see red, swollen epiglottitis during intubation (confirms dx)
CULTURE epiglottitis and blood
IV Abx to cover H flu and strep
○ Ceftriaxone IV for 3 days
○ Can switch to PO after for a 10 day total course
Can extubate within 24-48 hrs if epiglottitis much less swollen
54
What does a thumbprint sign on lateral radiograph suggest?
Epiglottitis
we avoid radiographs if suspecting epiglottitis as it can delay airway intervention
55
what is bacterial tracheitis?
"bacterial croup"
Severe life threatening form of laryngotracheobronchitis
invasive exudative bacterial infection of the soft tissues of the trachea
56
what pathogen most often causes bacterial tracheitis?
staph aureus (think also about MRSA)
(also strep pneumo, GAS)
57
what pathogen most often causes epiglottitis?
H flu in unimmunized kids
58
Typical age group of bacterial tracheitis?
first 6 years of life
59
presentation of bacterial tracheitis?
Croup sx (viral prodrome, barky cough, stridor, fever)
then high fever, toxic-appearing and worsened stridor and resp distress (progressive upper airway obstruction)
Unresponsive to standard dex and nebulized epi
60
key feature distinguishing bacterial tracheitis and epiglottitis?
epiglottitis = DROOLING and dysphagia, abrupt onset (no prodromal viral sx)
(drooling uncommon in bacterial tracheitis)
61
management of bacterial tracheitis?
AIRWAY - may need intubation if severe airway obstruction or pending respiratory failure
if intubated, rigid bronchoscopy to debride the airway
IV abx to cover staph aureus and H flu
(ceftriaxone)
62
diagnosis of bacterial tracheitis?
elevated WBC
lateral neck xray shows:
- Severe subglottic and tracheal narrowing ("Steeple sign" of croup)
- Irregularity of contour of proximal tracheal mucosa (= tracheitis) - see xray
Bronchoscopy shows:
- copious purulent tracheal secretions
cultured secretions grow staph aureus
63
Radiographic findings of croup?
Steeple sign
64
Croup patient unresponsive to dexamethasone and nebulized epinephrine - what is the most likely diagnosis?
bacterial tracheitis - Usual croup tx (dex/epi) NOT effective
65
What clinical features should warn you of impending complete airway obstruction?
toxic appearing and agitated/irritable
stridor
tripod or sniffing position
marked respiratory distress
66
upper airway obstruction with locked jaw (trismus) is suggestive of what underlying diagnosis?
peritonsillar abscess until proven otherwise
67
radiograph features of RPA?
Widened soft tissue pre-vertebral:
>7mm at C2 (1/2 Vertebral Body) or
> 14mm at C6 (whole vertebral body)
68
Typical age group of retropharyngeal abscess?
2-4 year olds (most likely age to get viruses)
69
Typical pathogens causing retropharyngeal abscess?
Group A Strep
Staph Aureus
70
Presentation of retropharyngeal abscess?
Fever + 4 D's
Dysphagia, Drooling, resp Distress, Dysphonia (muffled, hot potato voice)
*UNWILLING to extend neck (opposite of sniffing position of epiglottitis) / neck stiffness / torticollis
high overlap with epiglottitis but epiglottis is more rapid onset as compared to RPA which takes time to move through retropharyngeal infection -> cellulitis -> abscess
71
Imaging suggestions in stable patient with retropharyngeal abscess?
* Lateral soft tissue neck Xray (in extension and during inspiration) - shows widened pre-vertebral soft tissue *KNOW HOW WIDE COUNTS*
* Neck CT with contrast to confirm diagnosis and to differentiate retropharyngeal abscess from cellulitis.
72
Management of retropharyngeal abscess?
IV abx covering staph aureus, GAS and anerobes (eg Cefazolin + Metronidazole)
Surgical drainage of abscess if respiratory distress or failure to improve with IV abx
73
Complications of RPA?
Significant upper airway obstruction
Rupture leading to aspiration pneumonia
Lemierre’s Syndrome: Thrombophlebitis of the internal jugular vein
74
What is Lemierre’s Syndrome?
Complication from peritonsillar abscess or retropharyngeal abscess
= Septic thrombophlebitis of the internal jugular vein (IJV)
75
what is peritonsillar abscess?
Suppurative complication of strep pharyngitis (strep throat)
76
presentation of peritonsillar abscess?
Severe sore throat, *Trismus*, muffled hot potato voice, fever, drooling
enlarged, fluctuant tonsil/soft palate with DEVIATION OF THE UVULA to the opposite side
77
pathogens causing peritonsillar abscess?
Strep pyogenes (GAS), strep anginosus, staph aureus/MRSA, anaerobes
78
Diagnosis of peritonsillar abscess?
* Clinical dx: Asymmetric tonsillar bulge with contralateral displacement of the uvula
* US to distinguish PTA from peritonsillar cellulitis (different management if cellulitis or abscess)
79
Treatment of PTA?
Surgical Drainage, IV abx, IV fluids, analgesia
Empiric antibiotic therapy: clindamycin or ampicillin IV; amox-clav or clinda PO
(Before abscess drainage, the clinician should determine if the patient has indications for tοոѕillеctomу)
80
Pathophysiology of asthma exacerbation?
Airway inflammation, mucous plugging and bronchoconstriction
Results in:
- Hyperinflation (Obstructed small airways cause incomplete expiration, leading to air trapping)
- Hypoxemia (from V/Q mismatch)
81
Clinical presentation of severe asthma exacerbation?
-agitated
-decreased activity
-significant resp distress at rest (eg paradoxical thoraco-abdominal breathing)
-hunched forward using all accessory muscles
-audible wheezing
-O2 <90% on room air
82
what gives you points on the PRAM score?
Sats <92 (2 pts)
Sats 92-94 (1 pt)
Suprasternal retraction (2pt)
Scalene muscle contraction (2pt)
Decr air entry to bases (1pt), apex + bases (2pt), minimal/absent throughout (3pt)
expiratory wheeze (1pt)
insp and exp wheeze (2pt)
audible wheeze or silent chest (3pt)
83
define mild, moderate and severe asthma
PRAM 8-12 Severe asthma
PRAM 4-7 Moderate
PRAM <3 Mild
84
what is the management of severe asthma exacerbation?
PRAM 8-10, first try:
- Inhaled salbutamol with ipratropium q20min x 3
- oral steroids
- suppl O2
If poor response or PRAM 11-12:
- Suppl O2, CRM, NPO, 2 IVs
- continuous nebulized salbutamol and ipratropium x 60min
- IV steroids (anti-inflammatory)
- IV Magnesium Sulphate (bronchodilator)
- CXR, blood gas
- PICU consultation - consider ketamine, HFNC/non-invasive ventilation
AVOID INTUBATION
85
Presentation of asthmatic in impending respiratory failure?
-Patient drowsy/confused
-marked resp distress at rest (all accessory muscles and paradoxical breathing)
-ABSENCE of wheezing
-BRADYCARDIA
86
treatment of asthmatic in impending respiratory failure?
-call for help (PICU, anesthesia)
- pt NPO, keep calm
- 100% O2 non-rebreather +/- ventilation (bipap)
- consider TENSION PNEUMOTHORAX
- CRM, 2 IVs
- gas, lytes, support hemodynamics
- continuous nebulized salbutamol and ipratropium
- IV steroids
- IV mag
- IV salbutamol
87
what are mimics of a severe asthma exacerbation?
anaphylaxis, mediastinal mass, foreign
body, tracheomalacia, vascular ring/sling, heart failure (!!!!)
88
side effect of mag sulph in asthma tx?
mild hypotension - give fluid bolus
89
what is the main complication of status asthmaticus?
pneumothorax
esp consider if sudden change in a pt who had been improving
90
treatment of pneumothorax?
if small (<30% hemithorax) or stable, admit for observation and supplemental oxygen
if large or unstable or requiring transport, chest tube
91
typical presentation of primary pneumothorax?
Primary Spontaneous Pneumothorax
= pneumothorax that occurs in the absence of lung disease
More common in thin, teenage boys
Sudden onset, unilateral, pleuritic chest pain with or without dyspnea at rest
92
What is secondary pneumothorax and what are common etiologies?
Secondary Pneumothorax
= PTX occurs as complication of a disease process
Cystic Fibrosis (PTX occurs in 3% of CF pts during their lifetime)
Asthma (ruptured bleb)
Pneumonia with empyema
Marfan’s, Ehlers-Danlos, Ankylosing Spondylitis
93
what are the 4 toxidromes and examples of typical drugs for each?
Cholinergic (Physostigmine, Nerve Agents, organophosphates: herbicide, pesticides)
Anticholinergic (Jim and the "Anti-s)
- Jimson weed, Anti-histamines, Anti-psychotics, Anti-depressant (TCA like amitriptyline), Atropine
Sympathomimetic (PCP, cocaine, LSD, amphetamine, meth, MDMA, theophylline)
Opioid (morphine)
94
Opioid toxidrome?
constricted pupils (miosis)
bradycardia
hypotension
resp depression
95
96
what is tension pneumothorax and how do you treat it?
Tension Pոеսmοthоrах
=development of positive pressure in the pleural space
life-threatening emergency that causes hemodynamic compromise
dyspnea, hypotension, diminished breath sounds on the affected side, distended neck veins, and tracheal deviation away from the affected side
Immediate needle thoracostomy without waiting for a chest radiograph
Once stable, place chest tube
97
Presentation of cholinergic toxidrome?
Leaking from every orifice (diaphoretic, urinating, diarrhea, vomiting, coughing up water (bronchorrhea), lacrimating, salivating)
Memory aid: Just like we spray pesticides and nerve agents, these patients are spraying out
small fixed pupils (miosis)
Drowsy, confused
What kills them are the deadly B's: Bradycardia, Bronchospasm, Bronchorrhea (++watery sputum)
*Cholinergic is less common (usually barnyard pesticide ingestions and bio-terrorism) but highly tested
98
treatment of cholinergic overdose?
Antidote = Atropine
- 100% O2
- early ETT, avoid succ
- PPE, remove clothing, irrigate skin aggressively
- Atropine q5 min until secretions and wheezing stops
- Inhaled ipratropium (Atrovent) for bronchospasm
- Pralidoxime with atropine
99
what are drugs associated with anticholinergic toxidrome?
Jim and the "Anti-s"
- Jimson weed, deadly nightshade plants
- Anti-histamines (Benadryl and Gravol are the same molecule, just Benadryl has stimulant attached)
- Anti-psychotics (chlorpromazine, haloperidol, quetiapine, olanzapine) + Benztropine (which treats the movement side effects of antipsychotics)
- Anti-depressant (TCA like amitriptyline)
- Atropine
- eye drops! cyclopentolate (mydriatic eyedrop)
100
Presentation of anti-cholinergic toxidrome?
○ Agitated delirium
○ Large fixed pupils
○ Skin is flushed and dry (hyperthermic)
○ Increased HR and BP
"Hot as a hare": Fever
"Red as a beet:" Flushed skin
"Blind as a bat": Mydriasis (dilated pupils)
"Dry as a bone": Dry mouth, dry eyes and decreased sweating
"Mad as a hatter": Delirium, hallucinations, Agitated, picking the air, slurred speech
“Full as a flask” Urinary retention
101
ECG features of TCA overdose?
Prolonged QRS; Wide QRS complex tachyarrhythmia
102
Treatment of anticholinergic toxidrome?
Benzodiazepine (helps agitation) and/or Physostigmine (newer, preferred tx - reverses anticholinergic but do ecgs in case you overshoot and put them in cholinergic toxidrome)
Sodium Bicarbonate for Wide QRS complex tachyarrhythmia from TCA overdose
Evaporative cooling for hyperthermia (Antipyretics don't work)
Consider activated charcoal
Urinary retention may add to agitation - bladder scan + urinary cath
103
what are drugs associated with sympathomimetic toxidrome?
Cocaine
Amphetamine / Methamphetamine
MDMA (ecstasy)
Pseudoephedrine/Phenylephrine - in cold/flu medications
104
Presentation of sympathomimetic toxidrome?
- Large dilated pupils
- Diaphoretic
- Agitated, Hypervigilance, Paranoia, Psychotic
- Vitals increased = HR, BP, RR, Bowel sounds, Temperature (hyperthermia)
- Hyperreflexia, tremors, seizures
105
What differentiates sympathomimetic and anti-cholinergic toxidromes?
BOTH are dilated pupils, agitated, tachycardic/hypertensive
BUT anticholinergics are DRY and sympathomimetic is WET
memory aid - ANTI-perspirants of deodorants keep you DRY just like ANTI-cholinergic
106
how do we treat sympathomimetic toxidrome?
Benzodiazepines
107
Symptoms of MDMA (ecstasy) overdose?
HTN => HTN emergencies, ICH
Hyperthermia => rhabdo, DIC
Hyponatremia => seizures
Serotonin syndrome
Cardiac ischemia
Hepatotoxicity
108
treatment of MDMA (ectasy) overdose?
HTN => lorazepam => phentolamine
Hyponatremia => Fluids restriction or 3% NS
Activated charcoal if within 1 hour
Agitation => lorazepam
Hyperthermia => cool water mist and fans
109
Symptoms of LSD (Acid) overdose?
extremely potent HALLUCINOGEN (severe injury)
+ sympathomimetic toxidrome (Mydriasis, HTN, tachycardic, diaphoresis, hyperreflexia, hyperthermic)
110
Symptoms of Phencyclidine (PCP or “Angel Dust”)?
NYSTAGMUS
Miosis (constricted pupils)
seizures, delirium/paranoia/agitation
Dystonia/rigidity, myoclonus
CAN BE FATAL
111
Features of serotonin syndrome?
tremor, clonus, hyperreflexia
agitated, confused
elevated HR and BP
dilated pupils
diaphoretic
112
What is neuroleptic malignant syndrome (NMS)?
neurological emergency from antipsychotic ("neuroleptic") overdose characterized by:
1. RIGIDITY ("lead pipe")
2. agitated delirium
3. Fever
4. Dysautonomia of elevated HR and BP
113
key laboratory features of neuroleptic malignant syndrome (NMS)?
elevated CK (from the muscle rigidity)
114
treatment of neuroleptic malignant syndrome (NMS)?
stop antipsychotic
IVF since febrile/diaphoretic and to mitigate rhabdo from rigidity
cooling blankets for fever
If no improvement in 1-2 days, dantrolene or benzodiazepines (Can also use benzo for agitation)
115
serious side effect of many antidepressants?
prolonged QT
Citalopram/Escitalopram - Seizures, prolonged QT
Venlafaxine - Serotonin Sy, prolonged QT and QRS
Bupropion - Prolonged QT and QRS, seizures
TCAs - Prolonged QT and QRS
Quetiapine - Prolonged QT and QRS, hypotension
116
6 month old child presents to the emergency department with significant facial swelling and bruising. Given vital signs, tachycardia and hypotension with BP 60/40s. SpO2 99%. Respiratory rate is normal, pupils are equal and reactive. Most appropriate next steps?
a) CT head
b) Insert IO and give bolus of normal saline
c) Give mannitol
d) Intubate
this child is hypotensive
Insert IO and give bolus of normal saline
117
what factors influence oxygenation in mechanically ventilated?
FiO2 and PEEP = oxygenation
RR and tidal volume = ventilation
118
what factors influence ventilation in mechanically ventilated?
RR and tidal volume = ventilation
FiO2 and PEEP = oxygenation
119
Ex 28wkM CA 6mo with known pulmonary HTN intubated for RSV. You are called
for a sudden desaturation following tracheal suction. After confirming ETT position and patency, increasing FiO2 and giving sedation, your initial ventilation strategy might include:
a) Increase PEEP to decrease pCO2
b) Decrease rate to increase pO2
c) Increase rate to decrease pCO2
d) Increase tidal volume to increase pO2
Increase rate to decrease pCO2
120
when to admit an asthmatic to the PICU?
Previous history of near-fatal asthma
Inability to speak in sentences
Patients requiring > Q30-60min salbutamol
Decreasing LOC
Silent chest
PaCO2 > 40
Cyanosis with PaO2 < 70 with FiO2 > 40%
121
Risk factors for fatal asthma?
* history of rapid/severe deterioration
* Prior PICU admission +/- mechanical ventilation
* Syncope/seizure during attack
* >=1 Hospitalization or ED visit in last year
* >=1 canisters/month of rescue inhaler
* Poor compliance or understanding of disease management (Lack of an Asthma Action Plan)
* low SES, drug use, social problems
* comorbid heart/lung problem, obesity or food allergy
122
What role does heliox play in asthma pts who are critically ill?
heliox (reduces pulmonary airway resistance - makes air flow more laminar instead of turbulent)
- RC likes to ask about heliox. in real life, heliox is a bridge to something else (more time to get better, etc.)
123
list reasons why we avoid intubation in asthma
Increased Mortality
Tracheal FB causes Bronchospasm
Hemodynamic Instability
Increased Morbidity
124
when to intubate in asthma?
we REALLY try to avoid intubation. We are only going to do it to stop them from dying. we just need them to survive long enough to allow the respiratory muscles to rest
Indications:
* Severe and unremitting WOB (e.g. inability to speak)
* Persistent hypercarbia with PaCO2 >50 on NIPPV
* Hypoxemia despite high concentrations of FiO2 or NIPPV
* Altered mental status
* Respiratory or Cardiac Arrest
125
define shock
inadequate oxygen delivery which fails to meet metabolic demands of the body (tissue hypoxia, cellular dysfxn, cellular necrosis)
Shock => tissue hypoxia, cellular dysfunction and cellular necrosis
126
what is the equation defining cardiac output?
CO = HR x SV
127
shock is about blood pressure, right??!?!?
NOOO it is about oxygen delivery bruv !!!!
Delivery of oxygen is influenced by hgb, oxygenation, cardiac output and metabolic demand
128
what are the 6 different types of shock and examples of each?
Hypovolemic
- dehydration
- anemia
Obstructive (bc the blood can't get through)
- tension pneumothorax
- cardiac tamponade
- pulmonary embolism
Cardiogenic
- myocarditis
- arrhythmia
Distributive
- anaphylaxis
- sepsis
- neurogenic shock (spinal cord injury)
Dissociative
- CO/cyanide poisoning
Adrenal Crisis
129
what types of shock should you consider in trauma patients? (4)
-hemorrhagic
-obstructive (Tension PTX, cardiac tamponade)
-cardiogenic (myocardial injury)
-Neurogenic shock (spinal cord injury)
130
mixed venous oxygen saturation (SVO2) of <50% indicates what?
Limits of Extraction
(Beginning of Lactic Acidosis)
50-70 = compensatory extraction (high demand or low supply)
30-50 = Limits of Extraction
(Beginning of Lactic Acidosis)
<25 = cellular death
131
clinical features of shock?
aLOC
oliguria
132
therapeutic endpoints for shock?
Give enough fluid +/- vasopressors to:
Restore Age-Appropriate HR & BP
Normalize Capillary Refill Time
Restore/Improve Mental Status
Reverse Oliguria & Improve End-Organ Perfusion
you want to see the HR improve (fastest variable to watch)!
133
what should you look at in the patient to ensure they are beginning to respond to shock treatment?
heart rate
you want to see the HR improve (fastest variable to watch)!
134
10yo F presents to ED with high fever, vomiting & lethargy. Her vital signs included HR 150, BP 88/35, RR 40, Temp 40oC, Sats 93%. On exam, she is found to be flushed, CRT < 2 sec, with blotchy
erythematous rash on both her feet. She has no urine output for 24 hours. Which type of shock is this patient manifesting?
a) Compensated dissociative
b) Uncompensated cardiogenic
c) Uncompensated distributive
d) Compensated hemorrhagic
e) Uncompensated obstructive
Uncompensated distributive
uncompensated = altered mental status and/or hypotensive
distributed = flash cap refill and warm bounding pulses
135
13yo F with isolated TBI 48hrs ago. Clinical examination of the patient reveals findings consistent with brain death. A recent blood gas revealed SVO2 of 85% while an ABG taken at the same time revealed SaO2 100%. What is the most likely explanation for these results?
a) AVO2 difference is lower than normal which means nothing
b) AVO2 difference is lower than normal which means the patient is developing cardiogenic shock
c) AVO2 difference is lower than normal which means the patient is developing septic shock
d) AVO2 difference is lower than normal which means the patient’s brain is extracting less oxygen
AVO2 difference is lower than normal which means the patient’s brain is extracting less oxygen
think of AVO2 as the physiological analogue to SVO2
brain dead is delivering oxygen but there is no gas exchange, so AVO2 becomes very low
136
4 day old male presents with acidosis (pH 7.10, PC02 28) with hepatomegaly and poor
feeding. His oxygen saturations are 88% in room air. What is the next step in your
management.
a) Antibiotics
b) Prostaglandins
c) NPO and IV Fluids
need to give resuscitative fluids (bolus not IV infusion), antibiotics (most common is sepsis), then prostaglandins
137
what phoenix score defines sepsis and septic shock?
Phoenix Sepsis Score >=2
Septic Shock >=1 Point from the
Cardiovascular System
138
Child with fever, rash, hypotension. Cap refill is 5 seconds. What is the best
immediate management?
a) bolus D51/2NS at 20 cc/kg
b) bolus NS 20 cc/kg via central line
c) bolus 5% albumin
d) bolus NS 20 cc/kg via peripheral line
bolus NS 20 cc/kg via peripheral line
this is how we bolus
139
How to manage sepsis and septic shock?
Surviving Sepsis Algorithm:
Under 3 hr (and <1hr if septic shock), complete:
1. IV/IO access
2. blood cultures
3. empiric abx
4. measure lactate
5. 10-20ml/kg bolus fluids (reassess after EACH bolus, up to 40-60ml/kg total)
6. vasoactives if needed
7. treat hypoglycemia
140
Treatment of warm vs cold shock?
40-60ml/kg fluid
cold shock = epi (stimulates heart contractility and HR)
warm shock = norepi (vasoconstrictor)
start vasoactives at 0.05mcg/kg/min
141
at high doses, what is the mechanism of epi and norepi?
B1 (heart contractility), B2 (bronchodilation) and alpha (vasoconstriction)
142
12y M w/ pneumonia on general ward for 1L/min O2 and IV ampicillin
Day 2 of admission, increased WOB and 4L/min O2 for sat’s 93%. Remains alert, hemodynamically stable, dec. breath sounds L side. CXR shows interval white-out of L hemi-thorax.
Which one of the following is the most appropriate next step?
A. Place left-sided chest tube
B. Needle decompression of the left chest
C. Change antibiotics to vancomycin
D. Ultrasound of the chest
ultrasound of the chest - you want ultrasound confirmation of the empyema before you start poking holes in the patient (it could actually be atelectasis or consolidation)
then use TPA with chest tube daily
143
3 stages of empyema as a complication of pediatric pnuemonia?
exudative, loculated (fibronopurulent), organized fibrin peel
144
pathogens most likely to cause empyema as a complication of pneumonia?
strep pneumo, staph aureus, GAS
145
Pneumonia patient worsening
despite adequate antibiotics - what could it be?
This is likely an empyema.
Typically get a CXR which then prompts obtaining an ultrasound which confirms empyema (can be mistaken for atelectasis or consolidation)
146
treatment of empyema in complicated penumonia?
Consult IR/surgery
Chest drain
tPA via chest tube to manage loculations
147
Presentation of bronchiolitis?
acute viral infection (RSV and other viruses)
<24 months old
upper and small airway obstruction
148
treatment of bronchiolitis?
oxygen, calming, gentle nasal
clearance, NG or IV hydration
Epi neb trial in ED, only continue if helps
(any other therapy is not recommended)
149
Define pediatric ARDS
Syndrome of dysregulated pulmonary function in response to a local (direct) or systemic (indirect) stressor
150
Management of p-ARDS?
* Vt 6–8 mL/kg (as low as 4mL/kg if needed to limit pressures)
* Plateau Pressure ≤ 28 – 32 cm H2O
* Drive pressure ≤ 15 cm H2O
* Permissive hypercapnia (pH > 7.2)
* Sat target 92 – 97% (or > 88% in severe cases)
* Consider prone positioning and recruitment maneuvers
* Prevent fluid overload
* often generous PEEP (up to 10 – 15 cm H2O)
* HFOV still acceptable as rescue for pediatrics
151
what is the equation defining blood pressure?
BP = CO x SVR
BP = HR x SV x SVR
152
Equation we use to estimate hypotension cut off?
systolic BP of (2 x age in years) + 70
if >10 yrs, hypotensive if BP <90/60
153
rate of compressions in CPR? Features of successful compressions?
100 – 120 compressions / minute
Compressions should generate palpable pulse or EtCO2 > 15 mmHg
154
compressoin:ventilation ratio in intubated pts?
continuous compressions
20-30 breaths/min
(single rescuer = 30:2)
(2 rescuers = 15:2)
155
dose of epi during cardiac arrest?
0.01mg/kg IV/IO
= 0.1mL/kg of 0.1mg/mL (1:10,000)
156
4m M on ward w/ viral bronchiolitis
* Acutely deteriorated
* Appears pale/cyanotic, limp, saturations 50% and HR now 40 bpm
* Pulse present
What is the most appropriate next action?
A. Intravenous epinephrine
B. Intravenous atropine
C. Begin chest compressions
D. Bag-valve mask ventilate with FiO2 100%
E. Transcutaneous pacing
answer is D
Bradycardic WITH a pulse:
must oxygenate/ventilate first
then compressions if HR still <60bpm
then Epi
only atropine if vagally induced
then Transcutaneous pacing
(know PALS bradycardia with a pulse algorithm)
157
Management of a child (>1yr) with seizure >5min?
ABCDs - jaw thrust, clear secretions, 100% O2 by facemask, CRM, full vitals with temp, IVs, POC GLUCOSE, gas with lytes
STOP SEIZURE
1. benzo x 2 (5min apart)
2. fosphenytoin (IM/IV) or phenytoin or levetiracetam (Keppra - use if resp depression or hypotension). Try 2 different meds, then:
3. PICU admission with midazolam infusion
TREAT UNDERLYING CAUSE:
if blood glucose <2.6, give dextrose via rule of 50s -> 5ml/kg of D10W (5 x 10 = 50) via IV or 2ml/kg of D25W via central line (2 x 25 = 50)
assess for hyponatremia, hypocalcemia
Pupils/neuro exam: if raised ICP or herniation, treat immediately!
Ix: extended 'lytes, glucose, CBC-D, cultures, gas, anticonvulsant level, urine/blood tox
CT head if trauma, raised ICP, focal neuro deficits, aLOC unexplained
LP if no suspicion for raised ICP
Consider abx if suspicious for sepsis or meningitis
158
After benzodiazepine x 2, what is the next medication option to abort a seizure in an infant (<1yr)?
IV phenobarbital 20mg/kg
159
treatment of seizure caused by hyponatremia?
160
treatment of seizure caused by hypocalcemia?
161
treatment of seizure caused by hypoglycemia?
if blood glucose <2.6, give dextrose via rule of 50s -> 5ml/kg of D10W (5 x 10 = 50) via IV or 2ml/kg of D25W via central line (2 x 25 = 50)
check BG q 3-5min
rpt bolus as needed
162
Treatment for raised ICP?
163
A child is seizing who you suspect may have an undiagnosed metabolic disorder. She has failed to respond to first and second line medications to abort the seizure. What do you give?
pyridoxine (vit B6) 100mg by IV
164
Describe the principles of resuscitation of cardiac arrest?
CPR - minimize interruptions, full chest revoil, 1/3 of AP diameter of chest ~ 5cm (4cm infants)
if defibrillating, go straight into CPR x 2min then rhythm check
cuffed or uncuffed ETT fine
EtCO2 monitoring
Calcium if hypoCa, hyper-K or hyper-Mag
Hs and Ts
165
9y F unrestrained passenger in MVC, ejected onto nearby road. EMS brings to ED w/ C-collar applied. Exam: in response to painful stimuli, she opens her eyes, groans, and withdraws
What is her Glasgow Coma Scale score?
8
166
9y in MCV, GCS of 8
Which of the following will have the most detrimental effect on her
prognosis?
A. Hypoxia
B. Hypotension
C. Hypercapnia
D. Hyponatremia
hypotension - bc hypotension will cause the cerebral perfusion pressure to be compromised.
167
equation for central perfusion pressure (CPP)?
CPP = MAP - ICP
168
Presentation of DKA?
Polyuria, polydipsia, weight loss
Severe: reduced LOC, kussmaul breathing, significant dehydration
169
Diagnostic criteria for DKA?
Glucose ≥ 11.1 mmol/L
Ketosis: moderate urine ketones or BHB > 3
Acidosis: pH < 7.3, HCO3 < 15
* raised anion gap met acidosis
* Often transitions to hyperchloremic non-anion gap acidosis during treatment
* Anion Gap = Na – (Cl + HCO3)
[normal is 10 +/- 2]
170
classify DKA into mild, mod and severe
Mild: pH 7.2 – 7.29
Mod pH 7.1 – 7.19
Severe pH < 7.1
171
management of DKA?
fluid bolus over 1hr
then rehydration fluids (add K if serum K <5)
insulin infusion 0.1units/kg/hr
CRM, neurovitals, q1h gluc, q4 lytes and gas (alternating so results back q2h)
172
what are the rehydration fluid rates in DKA (depends on weight of child)?
5-10kg = 6.5ml/kg/hr
10-20kg = 6ml/kg/hr
20-40kg = 5ml/kg/hr
>40kg = 4ml/kg/hr
(this is from Hamilton)
173
what are the most common complications from DKA?
Cerebral Edema
HYPOglycemia
Initial serum HYPERkalemia followed by profound hypokalemia
174
symptoms of cerebral edema (eg in a DKA patient)?
decreased LOC
fixed or dilated pupils
hypertension
175
management of cerebral edema (eg in a DKA patient)?
Raise HOB
Decrease insulin/rehydration rates
3% saline bolus
176
ECG features of hyperkalemia?
in order:
1. tall peaked T waves
2. loss of P waves
3. widened QRS (K+ >7)
4. sinus waves, VT, asystole (K+ >8)
177
management of hyperkalemia?
1. Stop all source of potassium
2. Calcium gluconate 100mg/kg x1 (stabilize cardiac membrane)
3. Shift potassium intracellularly
- salbutamol nebulizer back to back x 3
- insulin BOLUS 0.1 units/kg (+dextrose 0.5g/kg) if not diabetic
4. Eliminate potassium
- Kayexalate to excrete into stool, or
- Furosemide to excrete into urine
178
formula for uncuffed ETT diameter size? cuffed?
Uncuffed = [(Age in years)/4] + 4
Cuffed = [(Age in years)/4] + 3.5
179
patient with hypothermia who is pulseless - treatment?
CPR
VF defibrillation (up to 3 shocks)
drugs are not effective until T >30
fresh frozen plasma if coagulopathy develops during rewarming
ECMO
180
Define hypothermia and associated features?
Hypothermia = core temp < 35 C
T 31-32 C: elevated HR and BP, loss of shivering at <32 C
T 28-31: bradycardic, hypotensive, flipped T, a fib, dilated pupils
T <28: arrest, VF, coma, fixed dilated pupils
181
metabolic derangements associated with hypothermia?
hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis
182
ECG features of hypothermia?
J waves (upward deflection btw QRS and T wave)
sinus bradycardia
prolonged QT
183
treatment of hypothermia?
ABCD
Remove wet clothes
heating blankets, bear hugger
IV fluids warmed to 43 degrees
warm humidified oxygen via ETT
Peritoneal lavage, ECMO, esophageal
warming tubes
184
presentation and treatment of synthetic cannabinoid ingestion?
Acute psychosis in children < 12 years
Edibles can lead to respiratory depression in toddlers
Supportive therapy and benzodiazepines if agitated
185
A 16 year old female has ingested “a handful” of her grandfather’s medication. Vitals: Pulse 48 BP 70/40
Resp 16 Temp 37 Glucose 17. What did
she most likely ingest?
A. Metoprolol
B. Digoxin
C. Losartan
D.Verapamil
this is a calcium channel blocker ingestion
answer is verapamil
186
presentation of calcium channel blocker ingestion?
hypotension and bradycardia (can be profound and refractory) - precipitous deterioration common!
May maintain pristine mental status despite
hypotension
hyperglycemia
187
treatment of Calcium channel blocker ingestion?
atropine q2-3min
calcium gluconate
*High dose insulin euglycemic therapy (HDIET)*
insulin infusion with D10W
188
