Final Flashcards
(137 cards)
1
Q
Cardiac and CNS toxicity may occur virtually simultaneously in infants and children due to
A
Lower threshold for cardiac toxicity with bupivacaine
2
Q
CNS and CV signs of LA toxicity include
A
Circumpolar numbness
Paresthesias
Lightheaded
Tinnitus
Seizure
Respiratory depression/arrest
Ventricular arrhythmia
Cardiac arrest
3
Q
Why is resuscitation effort after bupivacaine toxic dose difficult
A
Bupivacaine has affinity for Na, K, and Ca channels
4
Q
Bupivacaine is highly bound to plasma proteins specifically what 2 proteins
A
Alpha 1 acid glycoprotein
Albumin
5
Q
Lower levels of plasma proteins leads to what with bupivacaine
A
Increased free (unbound) fraction of LA that produces toxicity
6
Q
After accidental injection of large IV dose of bupivacaine progression from prod royal signs to CV collapse timeline
A
May be rapid
7
Q
To terminate seizure activity what drugs given
A
Midazolam 0.05-0.2 mg/kg
Thiopental 2-3mg/kg
8
Q
If cardiac arrest from LAST think
Treatment of choice
A
Intralipids
9
Q
Dose of intralipids
A
1.5ml/kg of 20% IV lipid emulsion
10
Q
Max dose of intralipids
A
3ml/kg
11
Q
Maintenance infusion rate of intralipids
When stop?
A
0.25 ml/kg/min
Until circulation restored
12
Q
Is propofol recommended as substitute for intralipids for LAST
A
No
13
Q
Supportive treatment of LAST with intralipids
A
IVF 10-20ml/kg isotonic
Vasopressors (NE or neo)
Antiarrythmic
Phenytoin
ECMO
14
Q
Conus medularis is located where in peds
Adults
A
L3 in peds up to 1 yr old
L1 adults
15
Q
Lumbar puncture for SAB/spinal in neonates and infants is performed at what level
A
L4-L5
L5-S1
Avoid needle injury to SC
16
Q
Tip of spinal cord in neonate ends at what level
When achieves normal adult position of L1-L2
A
L3
1 year of age
17
Q
Neonatal sacrum differences from adults
A
Narrower and flatter
18
Q
LP in older child may be performed where
A
L2-L3
L3-L4
L4-L5
L5-S1
19
Q
At birth spinal cord ends at what level
A
L3
20
Q
LP in infant may be performed at what levels
A
L4-L5
L5-S1
21
Q
Presence of deep sacral dimple may be associated with
A
Spina Bifida Occulta
22
Q
Presence of deep sacral dimple implications with caudal anesthesia
A
Greatly increases probability of dural puncture
Caudal block contraindicated
23
Q
CSF volume as percentage of body weight in infants/young children compared to adults
A
Greater in infants/young children
24
Q
CSF turnover rate for infants and children compared to adults
A
Greater turnover rate
25
Greater turnover rate of CSF in peds results in what changes in SAB
Much briefer duration compared to adults
26
SAB and epidural in infants and small children has what hemodynamic effect
Hemodynamically stable even when reaches upper thoracic levels
27
Why clinically significant BP changes do not occur in young children with SAB and epidural
PNS stronger than SNS
28
What position is patient placed into for caudal epidural
Lateral decubitus position
29
Palpate what for caudal epidural
Cornu of sacral hiatus
Found at the beginning of the crease of the buttocks
30
Appropriate insertion site of caudal epidural
Slightly more caudal from palpate sacral Cornu
31
What size IV cath for caudal block
22G
32
Needle direction initially for caudal block
45 degrees cephalad bevel down
33
Needle passes through what ligament for caudal block
Sacrococcygeal ligament
34
What space is caudal block placed into
Caudal canal
Continuous with epidural space
35
If bone is encountered before sacrococcygeal ligament do what
Withdraw several mm
Decrease angle to 30 degrees
Gently advance
36
As advance needle for caudal block what adjustments to angle
Decreased angle and nearly parallel to plane of child’s back
37
Intraosseous injeciton of LA results in what uptake
Very rapid uptake
Similar to direct IV injection
38
Drug dose for epidural blockade to a given dermatome level depends on what
Volume not concentration
39
Concentration of LA for epidural should be based on what
Desired density of block
Risk of toxicity
40
Where does spinal cord end in neonate
Lower border of L3
41
Neonate is undergoing surgical procedure with spinal. What would indicate high or total spinal?
Decreasing sat is earliest sign
Respiratory insufficiency rather than hypotension
CV markers stable bc PNS dominant
42
What is maximum dose of 0.25% bupivacaine that should be used for pediatric caudal anesthesia
How long anesthesia provided
1 ml/kg up to max of 25ml
Provides 3-6 hours for procedures below the diaphragm
43
Appropriate volume for pediatric epidural blood patch
Awake
Anesthetized
Awake- stop when child feels discomfort or pressure
Anesthetized- max 0.3ml/kg
44
Leading cause of death an disability in peds
Injuries
45
Up to 40% of polytrauma patients die as a result of what
Circulatory shock from acute blood loss
46
Besides surgical control of hemorrhage what is crucial for survival
Adequate volume resuscitation with blood products and IVF
47
Most common cause of death from injury for victims of all ages
Traumatic brain injury
48
Major threat to children in US
Vehicular trauma
49
Initial management and definitive care of child with traumatic head injury is focused on
Optimizing cerebral perfusion
50
Why optimize cerebral perfusion
Minimize extension of injury
Maximize recovery of damaged neuron
Managing extracranial injury simultaneously
51
Primary goals in management of peds trauma pt (9)
Delivery of oxygen
Appropriate ventilation
Vital organ perfusion
Normothermia to mild hypothermia
Assure renal function
Neurological stability
Correct coagulopathies
Avoid overhydration
Meticulous mgmt of metabolic demands
52
In emergency and shortage of 0- blood boys can receive what type
B+
53
Prepare for trauma patient with what in regards to weight
Estimated weight
54
Lidocaine bolus and infusion
1mg/kg bolus
20-50mcg/kg/min infusion
55
Adenosine dose
100 mcg/kg rapid bolus
Max 6 mg
200mcg/kg second dose
Max 12 mg
56
Amiodarone dose
5mg/kg
Max 300mg
VF and VT
57
Procainamide dose
5-15 mg/kg over 30-60min
Then 20-80mcg/kg/min infusion
58
Magnesium IV dose
25-50 mg/kg
Max 2 gm
Torsades
59
Calcium chloride dose
10-20mg/kg
Central line. Slowly
Stronger. More Ca per ml
60
Calcium gluconate dose
30-60mg/kg
PIV ok
61
Epinephrine
Hypotension
Cardiac arrest
1 mcg/kg hypotension
10mcg/kg arrest
62
Atropine max dose
Child
Adolescent
Child 1 mg
Adolescent 2 mg
63
No time for type and cross what blood given
O PRBCs
AB platelets and plasma
64
Women of childbearing potential should receive what type of blood
O negative RBC
65
Men and women post-childbearing age could receive what type
0 positive PRBCs
66
PRBCs 4 ml/kg increases Hgb bu how much
1g/dL
67
What dose of PRBCs increases Hgb by 1 g/gL
4 ml/kg
68
Platelet transfusion of what dose increases platelet count 50K-100K
5-10 ml/kg
69
FFP transfusion of how much increases factor level by 15-20%
10-15ml/kg
70
Platelet infusion of 5-10ml/kg will increases platelet count by how much
50,000-100,000
71
FFP transfusion of 10-15ml/kg increases factor level by how much
15-20%
72
Cryoprecipitate given to increase what level
Fibrinogen
73
Cryo dose of 1-2 units/kg increases fibrinogen how much
60-100 mg/dL
74
To increase fibrinogen by 60-100mg/DL dive how much cryo
1-2 units/kg
75
Lethal trauma triad of death
Coagulopathy
Acidosis
Hypothermia
76
How coagulopathy leads to acidosis
Increased lactic acid in blood
77
How acidosis to hypothermia
Decreased heart performance
78
Hypothermia to coagulopathy
Decreased coagulation
79
Platelets should/should not be refrigerated
NOT
80
If overt signs of bleeding present or more hemostatic challenging procedure imminent what platetlet level may be required
30,000 to 50,000/mm3
81
Platelet should be give through what type of filter
Large-pore filters
>150nm
82
FFP contains what
All clotting factors and regulatory proteins
83
What patients could benefit from higher FFP:RBC ratio of 1:1
Massively transfused patients
84
Increased FFP transfusions to massively transfused patients associated with
Trend toward increased mortality
Increased risk of TRALI
85
Rapid administration of FFP can cause
Citrate toxicity
86
S/S hypochloremia
Hypotension and arrhythmias
87
Citrate intoxication may be more likely in setting of
Hypothermia, liver disease/transplantation
More likely in pediatric patients
88
Citrate is mainly metabolized where
Liver
89
Citrate has what effect in blood stream
Binds calcium
90
Cryoprecipitate contains what factors
Factor VIII
Von willebrand factor
Factor XIII
91
Cryoprecipitate indicated for what
Factor XIII deficiency
Dysfibrinogenemia
Hypofibrinogenemia
92
MABL formula
EBV X (Hct-maHct)
—————————-
Hct
Minimum accepted Hct (maHct)
93
Cryoprecipitate contains how much factor VIII from original plasma unit
20-50%
94
Formula for volume of PRBCs to be transfused
EBV X (desired Hct - current low Hct)
————————-
Hct of PRBCs- 60
95
Hct of unit of PRBCs
60
96
Child with severe pulmonary disease or cyanotic heart disease requires ___________ Hct than healthy child
Higher Hct
97
Preterm infants may require _______ Hct
Greater
98
Why do preterm infants require higher Hct
To prevent apnea
Reduce cardiac and respiratory work
Improve neurologic outcomes (possibly)
99
If little potential for post op bleeding Hct level of _____ is acceptable in healthy infants put to 3 months
20-25%
100
If little potential for post op bleeding what Hct is acceptable in older healthy children
>3 months
20%
101
Risk of spine injury in peds patient is increased when child is subjected to (2)
Inertial forces from falls
Chaotic rotary forces from MVA
102
Any child with suspected neck injury should have
C spine precautions
103
_________ should always be maintained when airway manipulation attempted in suspected neck injury
In line stabilization
104
How many people may be required to intubate child with cervical fracture
Roles
4
1 for inline stabilization
1 to do intubation
1 for cricoid, hold ETT
1 to give drugs
105
Initial management of severe brain injury must first focus on
Actual pathophysiologic process that occurred at point of impact
106
Useful for initial and ongoing assessments of severity of CNS injury
GCS
Modified GCS for peds patients
107
Regardless of whether brain injury due to trauma or secondary due to global hypoxia there is
Immediate disruption of integrity of BBB
Results in cerebral edema and diminished neuronal oxygenation
108
Modified GCS for peds
Verbal response rankings
5- babbles, coos
4- cries but inconsolable
3- persistent crying or screaming in pain
2- grunts or moans to pain
1- none
109
Modified GCS is applicable to what patients
Eye opening and motor < 1 yr
Verbal response < 2 years
110
Children with head trauma may have minimal neurologic abnormalities at time of initial evaluation, however
Increased ICP and neurologic deficits may progressively develop
111
Increased ICP and neurologic deficits occur slowly in how many stages
2
112
2 stages of brain injuries
Primary insult
Secondary insult
113
Primary insult of deficit occurs when
Results from
Time of impact
Results from biomehcanical forces that disrupt cranium, neural tissue, and vasculature
114
Secondary insult of neurologic deficit is
Results from
Parenchymal damage caused by sequence subsequent to primary insult
Results from hypotension, hypoxia, cerebral edema, or intracranial hypertension
115
Ventilation of children with cerebral injury should maintain PaCO2
Between 35-40 mm Hg
116
Avoid/do mild hyperventilation in patient with cerebral injury
AVOID
117
Hyperventilation even mild should be avoided. Why?
Decreased blood flow to area surrounding injured area. Worsening flow to area
118
Calming the brain involves
Immediate administration of opioids and benzos
Seizure prophylaxis
***alters neuro exam***
119
What commonly given for seizure prophylaxis
Phenytoin
Phenobarbital
120
____________ should be considered when caring for children with AMS, Sz, or associated trauma requiring surgery
Basilar skull fracture
121
Findings associated with basilar skull fracture
Raccoon eyes
Retro auricular ecchymosis (battle sign)
Hemotympanum
Clear rhinorrhea
Otorrhea
122
Avoid what in possible basilar skull fracture
nasal intubation
NG tube
123
Acute subdural hematoma is most dangerous. Generally caused by what
Severe head injury
124
S/S of acute subdural hematoma occur when
Immediately usually
125
Due to rupture of usually veins between brain and dura
Subdural hematoma
126
Rupture of blood vessel between dura and skull
Epidural hematoma
127
Epidural hematoma
What BV usually rupture
Artery
128
As epidural hematoma expands leads to what s/s
Loss of consciousness
Hemiparesis
Pupillary dilation
129
Treatment of epidural hematoma
Prompt surgical evacuation
130
Medical therapy with epidural hematoma should be aimed at
Decreasing ICP
131
Acute subdural hematoma is almost always r/t
Trauma and frequently result of abuse
132
Shaken baby syndrome leads to what
Acute subdural hematoma
133
MOA of shaken baby syndrome
Infant so vigorously shaken that accelerating and decelerating rotational forces cause bridging veins to rupture
134
Blood vessels most susceptible with shaken baby syndrome
BV leading from brain to dura
135
In 50-80% of shaken baby syndrome what is presence
Unilateral retinal hemorrhage
136
Any bruises in what areas must be suspect for abuse
Buttocks
Groin
Neck
Cheeks
137
Age of children at highest risk for maltreatment and subsequent mortality
3 and under
