Hospital Pediatrics and Acute Care Flashcards

Question

What issues with ABCD do you anticipate in Status epilepticus ?

Answer 1

* Airway *(jaw clenching, secretions)* * Do **NOT force** jaws open * **Suction** and lateral decubitus * Intubate if concerns after seizure abortion * Breathing *(aspiration pneumonitis, atelectasis)* * **100 % oxygen** on rebreather * 2+ doses of benzodiazepines give resp. depression * Phenobarbital is notorious for resp. depression. * Circulation *(Collapse from hypoxia or seizure aetiology typically)* * Look for **Cushing's Triad** *(HypTN, bradycardia irr. breathing)* * Have **2** large bore **IVs** placed * Disability *(neurologic stuff)* * Look for **focal neuro**logic signs or **cortical** signs * Have **3 % Saline** at bedside if concerned for **ICP** * Seizure abortion algorithm

Answer 2

The PRAM score is used to determine the severity of an asthma exacerbation and the response to therapy It is calculated be examining the **Air entry** (0-2), **Wheeze** (0-3). **Oxygen saturation** (0-2), **Suprasterna**l (0-2) and **Scalene** (0-2) accesory muscle use. *Attached in a table describing the proper determination of PRAM scoring.*

Answer 3

* **Etomidate** is your rapid seq. intubation med *(except for sepsis)* * Use **ACTUAL weight** not ideal weight in obese resusciation * **Don't** use **cricoid** pressure

Answer 4

1. Vital sign **monitoring standards** *(anticipate events)* 2. Calling/Early **warning** systems *(respond to events)* 3. Planned **response team**/arm of hospital *(people for events)* 4. **Quality control** of implementation 5. **Education** for all caregivers on implementation

Answer 5

* Compresses **1/3 of thorax** depth * Allow full **recoil** * **Change** people every **2 mins** * **\< 5 second** pause between **person change** * **\< 10 sec** **pulse** checks

Answer 6

* Barking / Stridor * Intermittent *(Mild)* * At rest *(Moderate)* * Constant *(Mod-Severe)* * Respiratory Distress * None *(mild)* * Intermittent *(mild-mod)* * At rest *(Moderate)* * Constant *(Moderate-severe)* * Decompensation * CNS changes *(severe)* * Persistent respiratory distress *(severe)* * Cyanosis *(impending respiratory failure)*

Answer 7

* **10-30%** of admissions for Bronchiolitis have **several viral** co**infections** * **~30 %** of children **will get bronchiolitis** between 0-2 y.o. * **\< 3 %** of bronchiolitis present with **apnea\*** ## Footnote *\***Exceptions include ex-prematures, personal history of apnea, and previous cardiorespiratory pathologies*

Answer 8

Step 1: Have a **written BF policy** Step 2: **Enable** all providers to **implement** the BF policy. Step 3: **Inform mothers** and **families** about breastfeeding. Step 4: Immediate **post-natal skin-to-skin** (1 h min) Step 5: **Assist** mothers to breastfeed and **maintain lactation**. Step 6: Support mothers to **exclusively breastfeed** for the first six months, _unless supplements are medically indicated_. Step 7: **Facilitate 24-hour rooming-in** for _all_ mother-infant Step 8: **Encourage baby-led** or cue-based breastfeeding. Step 9: Avoid False nipples *(Contradicts other CPS statements)* Step 10: Provide **seamless transition** from hospital to community health services and peer support programs.

Answer 9

* **QT Prolong**ation (*no ECG needed if no risk factors\*)* * **Pseudotumour** cerebri *(no screening needed)* * Pro-kinetic **diarrhea** *(last 2 days, no additional management needed)* ## Footnote *\*Risk factors to screen for include family history of sudden cardiac death, known Long QT syndrome, chronic medications with QT prolongation or active acute medications with QT prolongation.*

Answer 10

* Mild *(PRAM 0-4)* * Salbutamol (0.3 puff/kg) Q20 min x3 * Increase inhaled steroid, consider systemic * Re-assessment after 1 h * Moderate *(PRAM 5-8 or no change from prev. assessment)* * Salbutamol (0.3 puff/kg) Q20 min x3 * Ipratroium Bromide with initial Q20 salbutamol\*\* * Salbutamol (0.3 puff/kg) Q 30min *as needed* * Systemic corticosteroids *(PO if tolerated)* * Re-assessment after each salbutamol * Severe *(PRAM 8+)* * Move to obervation area of ED, notify PICU if impending respiratory failure or concerned * Salbutamol (0.3 puff/kg) Q20 min x3 * Ipratroium Bromide with initial Q20 salbutamol\*\* * Consider continuoues Salbutamol *(5 mg in 2mL)* * Systemic corticosteroids *(PO if tolerated but likely IV)* * Consider High Flow Nasal Cannula * Obtain Chest X-ray * Obtain baseline electrolyte, blood gas *(if RF suspected)* * Prepare saline bolus *(20 ml/kg)* * Prepare Magnesium Sulfate *(25-50 mg over 20 min)* * Re-assessment after each salbutamol

Answer 11

1. Oral anti-biotics *(typically Amoxicillin is sufficient x7-10 days)* 2. Return if worsening symptoms or no change in **48 h** 3. CXR or Ultrasound if physical suggests pleural effusion. *(In otherwise healthy kids, CPS specifcallly discourages CT scans)* 4. If the effusion is: 1. Small: IV anti-biotics until off oxygen and clinical condition improves 2. Moderate: Drain chest and IV anti-biotics until improvement 3. Large or Complex: rain chest, IV anti-biotics, consider thoracoscopic intervention or TPA\* 5. Send Chest Fluid for culture\*\* **_and_** S. *pneumo* **PCR**. 6. Once **vitals normal**ise and **clinically** **improving**, can switch to PO anti-biotics for 3-4 weeks. 7. **Follow-up CXR** in **3-4 Months** is acceptable by the CPS ## Footnote *\*TPA dose is 2 mg in 30-50 mL saline in the tube BID or 4 mg in 30-50 mL of saline in the tube daily x 3 days. \*\*Odds of growing something are low as patient is already on Abx.*

Answer 12

* **Cushing's** triad *(Hypertension, bradycardia, abnormal breathing)* * **Papilledema** * **Focal neuro**logic findings * History of head **trauma** *CT scans should be reserved for when the patient is hemodynamically stable enough for the scan*

Answer 13

Immune modulated destruction of otherwise normal platelets * **\< 100 x10⁹** platelets/L * **No red flags\*** for other hematologic pathologies *\*Bone pain, B-symptoms, recurrent thrombocytopenia, poor treatment response*

Answer 14

* **Audible wheeze** on exam\* * with any of the following* * Objective **reversal** of obstruction with **bronchodilators**\* * Patient or Family **History** of **atopy** * **Previous** emergency room/admission of asthma **exacerbation** *(essentially the same as documented reversal)* * **No other diagnosis** to explain the wheeze *(Cystic fibrosis, bronchiolitis, foreign body, auto-immunity, aspiration pneumonitis)* *\*A family's consistent, and appropriate description of these symptoms can be an acceptable surrogate for your own objectification.*

Answer 15

* Bloodwork * CBC + differential *(if febrile)* * Gucose * Complete electrolytes *(Na, K, Cl, Mg, Ca, PO₄)* * Renal profile *(BUN, Creatinine, NH₄)* * Blood Cx *(if febrile)* * Urine tox screen * Anti-epileptic levels *(Valproate, Lamotrigine)* * Blood Gas *(if respiratory or ingestion concerns)* * Imaging * CT head *(If suspected ICP or Head trauma)* * Chest X-ray *(if persistent respiratory issues)*

Answer 16

Glucagon load followed by infusion ## Footnote *This is particularly important for patients with anaphylaxis*

Answer 17

1. Neonate 1. **2 mL/kg D10W** bolus 2. Increase GIR through most optimal modality 3. Recheck in 5 minutes 2. Status epilepticus 1. **5 mL/kg D10W** bolus 2. Have IVF with D5W running 3. Recheck in 5 minutes

Answer 18

* **Oromotor dysfunction** WITH aspiration risk * Progressive decline in **neuromuscular** **function** * Insufficient **nutritional intake** * Insufficient **tolerance** of oral **medications/therapies** * **Anticipated need** for **\> 6 months** of assisted enteral feeding ## Footnote *Whenever the above is suspected or expected, approach the idea of G-tubes as early as possible as per CPS*

Answer 19

* Leadership; *(organise, direct, synthesize, delegate..)* * Situation Awareness; *(Anticipate progression, note response to therapy)* * Resource Allocation; *(Best person for best job)* * Communication; *(One leader, closed loop, respectful yet direct)*

Answer 20

_Maternal Contraindications_ * **HIV** Positive *(in 1st world countries)* * Active infection with *Tuberculosis, Ebola, T-cell lymphotrophic viruses, brucellosis* * **Active Herpetic** lesion **on** the **breast** *(can use other)* * Cannot breastfeed but CAN give EBM if acutely ill with influenza, varicella (- 5 days to +2 days of birth) * **Cytotoxic chemo**therapy and Isotope **radio**therapy *(Start Wean immediately to prevent stress on baby)*

Answer 21

* 9 - 24 % of hospitalised childiren on IVF have hyponatremia * Admitted Paediatric patients secrete more ADH, particularly: * Respiratory Diseases *(bronchiolitis, asthma, croup ...)* * Cardiac Disease *(Heart failure, post-arrest, shock)* * Neurologic Diseases *(any CNS disease, head trauma)* * Peri-surgical patients *(any surgery, ortho paricularly)*

Answer 22

1. **O**₂sat goals of **94-99 %** *(100 % increase reperfusion injury risks)* 2. Closely monitor **IN/OUT** *(low cardiac eff., resus ichemia = 3rd spacing)* 3. Assess **organ function** *(Renal/Liver profile, CBC, Blood Gas)* 4. **2 days** of therapeutic **hypothermia** *(32ºC - 34ºC)* 5. **EEG** within **7 days** 6. **NO** seizure **prophylaxis** 7. **Call** for Spiritual Care/**Family Support** ## Footnote * All post-acute care should go through the A, B, C, D(isabilities) and F(amily)* * Circulation includes C1: Volume, C2: Perfusion and C3: Rhythm*

Answer 23

* Croup is primarily seen in **6 months to 3 years** of age * **\< 1 %** of Croup develops **severe**/refractory symptoms * **3-5 % of emergency** department **visits** are croup! * **60 %** of barking coughs **resolve in 48 h** after onset * Aetiologies include: * **Parainfluenza** viruses 1, 2 and 3 * Influenza A /B * RSV * Adenovirus

Answer 24

1. **Assess** for Mild, Moderate, Severe or Impending Failure 2. **Consider** possibility of **differential** diagnoses\* 3. **_Steroids_** for everyone *(Dexamethasone 0.6 mg /kg PO x1 has evidence)* 4. **Inh**aled **epi**nephrine for mild/severe 5. If tolerating PO, no or improving respiratory distress and otherwise well - discharge home with return intructions. ## Footnote *\*Differential includes epiglotitis (no cough? vaccines?), tracheitis (toxic/febrile no inh. epi response), retropharyngeal abscess, foreign body (biphasic stridor, otherwise well, acute development), anaphylaxis)*

Answer 25

* **No red flags** on asthmatic history unaccounted for * Hemodynamically stable with **salbutamol Q4+h** * **\> 94 %** O₂ **sat**urations on room air *(or baseline O₂ needs)* * Minimal to **no** respiratory **distress** * Good or improved **air entry** bilaterally * **Family is comfortable** with appropriate aerochamber/inhaler technique * **Follow-up** with asthma clinic or Family doc is arrange

Answer 26

* **Low flow Oxygen - Recommended, strong evidence** * **High flow Oxygen - Recommended, growing evidence** * **Hydration Support - Recommended, strong evidence** * *Nebulized epinephrine (racemic) - equivocal* * *Corticosteroids - Dexamethasone with Epi. equivocal* * _Nebulized 3 % Saline - NOT recommended_ * _Anti-viral therapy - NOT recommended_ * _Empirical antibiotics - NOT recommended\*\*\*_ * _Chest physiotherapy - NOT recommended_ \*\*Anti-biotics are only to be given is a suspicion for secondary infection or concomitant pneumonia. NG was found to be equivoval to IV rehydration therapy, for admission duration as an outcome.

Answer 27

1. **Endoscopic** Guided percutaneous insertion 2. **Laparoscopic** surgical implantation 3. **Interventional Radiological** percutaneous insertion ## Footnote *The procedure can be done by Interventional Radiology, General Surgery or (rarely) Gastroenterology depending on your center*

Answer 28

* Asthma lifetime **prevalence** is **11 - 16 %** * ~ 50 % asthma exacerbations are in children \< 5 y.o. * About **10 %** of children with asthma, report presenting to the emergency department in the last 2 years for their asthma.

Answer 29

**_0.15 mg/kg PO_** ## Footnote * x 1 (outpatient) or Q8H (inpatient)* * Larger dosing tends to be in increments of 2 mg; CPS suggests 8 -15 kg get 2 mg, 15 - 30 get 4 mg and greater than 30 mg can titrate 6 - 8 mg.*

Answer 30

* Status epilepticus' **annual** incidence is **1 - 156/100,000** * Status epi. has a **2-8 % mortality**, and a _10-20% morbidity_ * **5-19 %** of status epi. cases are **idiopathic** * Prolonged **Febrile seizure** account for **23-30 %** cases * **Acute events** are 17 - 52 % of cases, including : * CNS infection or reactivivity *(meningitis, encephalitis)* * Metabolic derangement *(glucose, electrolytes,)* * Anti-epileptic withdrawal/OD *(consider non-compliance)* * Pharmaceutical/Illicit drug overdose * **Remote aetiologies** from young age are **16-39 %** * Perinatal/Congenital disorder exacerbation *(e.g. stroke)* * Progressive **neurodegenerative** disease

Answer 31

* **1 - 4/1000** Emergency Dept. presentations are **anaphylactic** * **Only 1/3** of Anaphylactic presentation **find a trigger** * Systemic symptoms for anaphylaxis include: * **Skin** / Mucosal Involvement ***(80 - 90 %)*** * _Respiratory_ Distress *_(60 - 70 %)_* * **Cardiovascular** changes ***(10 - 30 %)*** * Gastrointestinal Changes * CNS alteration secondary to poor perfusion *(CVS)*

Answer 32

* Chest X-ray; *i**f strong suspicion for concomitant/secondary pneumonia, atypical disease progression or severe disease* * Nasopharyngral aspirate/Swab for Virus Panel; *only recommended for research/epidemiology cohorting* * CBC and differential; *does not change management* * Blood Cultures; *severe disease,* *not recommended routinely* * Urine Culture; *n**ot recommended routinely*

Answer 33

1. **Lorazepam** 2 - 4 mg IV x 2 doses\* *(IN midazolam is also an option)* 2. **Phosphenytoin** 20 mg/kg over '20 min IV' or IM 3. Sodium **Valproate** *(growing evidence for preference over phenobarbital)* 1. **Loading** dose **30 mg/kg** over 5 minutes 2. then 10 mg/kg Q8h IV maintenance 3. **10 mg/kg IV PRN** Q8h are allowed **after first bolus** 4. **Phenobarbital** 20 mg/kg over 20 min IV 5. *Trial Pyridoxine 100 mg if refractory in child \<3 y.o.*

Answer 34

* Bronchiolitis * Obstructive Sleep Apnea * Asthma\* * Pneumonia / inhallation pneumonitis * Heart Failure\*\* ## Footnote *\*Be wary that HFNC can worsen the symptoms of breath stacking, lower flows can be better for asthmatics. \*\* The intrathoracic pressure is increased acutely with HFNC, however pulmonary hypertension will improve with better oxygenation over time. Be aware of this with corpulmonale or RV-failure.*

Answer 35

* **Retention** of PALS/NRP/ACLS is **\< 3-12 months** if not used * Hospital Rapid Response Teams **decrease** pediatric Cardiopulmonary **arrest** by **37.7** %, **mortality** by **21.4** %

Answer 36

_Acute Complications of Sickle Cell Anemia/Disease_ * **Hemolytic** Anemia * **Occlusive** Syndromes *(both occlusive and reperfusion crises)* * Results of **End Organ Damage** *(renal, hepatic, skin, heart and lung)*

Answer 37

_Management of Acute Pain Syndrome (SCD)_ 1. **Calming environment**/private room (Child life) - *WARM compresses only* 2. **Fentanyl IN 1-2 μg/kg**/dose (50 μ/mL solution split between both nostrils) 3. Place **IV at maintenance** until PO is tolerated then titrate downwards 4. Oxygen Saturations **\> 95 %** 5. Acetaminophen 15 mg/kg Q6h - *HOLD IN LIVER INSUFFICIENCY* 6. Ibuprofen 10 mg/kg Q8H - *HOLD IN RENAL INSUFFICIENCY* 7. **Morphine 0.2-0.5 mg/kg** **PO** Q 4-6h *(with half dose PRN)* 8. PEG 3350 as per formulation *(non-urgent)* 9. Consider Discharge if Family is comfortable, patient is maintaining PO fluids and pain management. 10. Daily Phone Follow-up with Clinic Follow-up that week

Answer 38

_Management of Acute Chest Syndrome (SCD)_ 1. **Calming environment**/private room (Child life) 2. **NPO & NG** tube when possible 3. Oxygen Saturations **\> 95 %** 4. **Fentanyl IN 1-2 μg/kg**/dose (50 μ/mL solution split between both nostrils) 5. Place **IV at ½ maintenance D5W-NS + Lytes** ***(Ideally TPN)*** 6. Draw bloods with **CBC & diff., Blood Cx, Hemolytic Profile, Crossmatch** 7. **Beta-lactam AND macrolide** anti-biotics 8. **Morphine 0.2-0.5 mg/kg** **PO** Q 4-6h *(with half dose PRN)* 9. **NPA** viral panel and M. *pneumoniae* PCR 10. Chest X-Ray and obtain previous CXR records 11. Consult **PICU** and **Hematology** 12. PEG 3350 NG as per formulation *(non-urgent)*

Answer 39

**Sick Febrile Patients with SCD should be managed aggressively.** *These points from the CPS are here to reassure conservative management.* * **First presentation** for this episode * Well appearing and ^*hemodynamically **stable** * **Pain controlled** and tolerating PO fluids and medications * Fever \< 40 °C * \> 6 months old * ^$Normal or elevated Cell Counts * Normal ^#neurologic, \*Respiratory, ^%MSK, ^$Abdominal Exams * ^*Stable CXR - *old consolidations/opacities can be present* * **^#No** history of **severe pneumococcal** infection *(meningitis or sepsis)* * Solid Discharge and **return-to-care plan** *\*Checking for early Chest Syndrome ^#Checking for early meningitis ^$Considering aplastic crises and possible sequelae ^%Osteomyelitis, septic joints and cellulitis*

Answer 40

_Opioids in Paediatrics_ * **Morphine** * Well understood and relatively safe to use * Large First Pass effect so _beware_ in patients with _hepatic insufficiency_ * **PO for sustained pain** control with *IV boluses for short-term* pain control * **PO DOES NOT EQUAL IV for dosing** * **Fentanyl** * Bridge for pain control to **facilitate IV placement** *(and* *Δ* *to morphine)* * Requires vital _monitoring_ - **not a long-term solution for pain.** * Oxycodone - *Don't use due to risks associated with hyper-metabolizers* * Hydromorphone - *Don't use due to risks associated with hyper-metabolizers* * Codeine - *Don't use due to risks associated with hyper-metabolizers* * Tramadol - *Codeine analogue so avoid due to metabolic concerns*

Answer 41

**Oxygenation Index (OI)** Describes the presence of a *V/Q mismatch*; where a larger number represents a massive dependance on ventillatory support, or a very small result of arterial oxygenation **OI= (FiO2 x Mean Airway Pressure)/ PaO2** *< 10 is our typical goal, but this should be measured dynamically with your clinical management*

Answer 42

**Oxygen Saturation Index (OSI)** A postulated surrogate for OI when arterial lines aren't possible. Describes the presence of a *V/Q mismatch*; where a larger number represents a massive dependance on ventillatory support, or a very small result of arterial oxygenation **OSI= (FiO2 x Mean Airway Pressure)/ SpO2** *< 10 is our typical goal, but this should be measured dynamically with your clinical management*

Answer 43

Absolute Neutrophil Count (ANC) < 1.5 x 10^9 cells/L *Severe Neutropenia is < 0.5 x 10^9 cells/L*

Answer 44

_Conservative Therapy for Febrile Neutropenic_ - **Normal physical exam**, other than fever and associated mild tachycardia - Isolated neutropenia *(other cell lines are normal)* - **No** history of **chronic disease** - **No** history of medical **implants** or foreign bodies - Availability for **close follow-up** - Well appearing - Must not be severely neutropenic

Answer 45

**EVENDOL ; 0-7 y. o. for urgent care, clinic and ED visits** *CHEOPS ; 2-22 months for post-operative pain* **FLACC ; 2 months - 7 years for physical responses to pain** *r-FLACC ; 4-19 y. o. with developmental deficits* **NIPS ; Newborns and infants** *COMFORT ; intubated patients of all ages*

Answer 46

_CPS Definition of DKA_ Mild : pH 7.2-7.29 with HCO3 between 10-18 mM Mod : pH 7.1-7.19 with HCO3 between 5-9 mM Severe : pH < 7.1 with HCO3 < 5 mM *To confirm DKA as the cause, you need to identify >3 mM of B-hydroxybutyrate (BHB) and hyperglycemia > 11 mM. The anion gap will be elevated from the BHB*

Answer 47

_Goals for Management of DKA_ (1) Rehydration with **isotonic** fluids *(NS + KPO4)* (2) Normalization of pH *(occurs with rehydration and insulin NOT bicarbonate bolus)* (3) Cessation of **ketosis** *(occurs with insulin infusion)* (4) **Correct electrolyte** imbalances *(Na, K, PO4, Cl), Mg, Ca)* (5) Normalization of glucose (6) Management of precipitating *(or coexistent)* factors (7) Prevention of secondary electrolyte imbalances from therapies *The goal is to have frequent follow-ups with biochemistry, and slowly normalize the patient to avoid sequelae. Thus the best management involves the placement of a **central line, arterial line** and availability of a **blood gas machine** that can measure ketones, glucose and a full electrolyte panel confidently.*

Answer 48

Fluid Resuscitation Options for DKA The correct fluids include Normal Saline, Ringer's Lactate and Plasmalyte. 1/2NS+D5W should be avoided early on, and absolutely with any neurologic changes. - Initial dose: **10-20 mL/kg (maximum of 1000mL)** over _30 minutes_ - Hemodynamic bolus : **10 mL/kg bolus** to a maximum of 40 mL/kg in consultation with PICU (and neuro vitals) - **Maintenance + deficit** should be given over _36 h_ as per the following formula.

Answer 49

**< 5 mM/h** *(This should be slowed by adding dextrose to the infusion, NOT decreasing the insulin)*

Answer 50

_When to start Insulin during DKA_ - _*1 hour*_ of fluid resuscitation has already passed - *Potassium is > 3 mM* (can add to fluids prior to the 1 h mark) *You can start at 0.05 units/kg/h to a max of 0.1 unit/kg/h titrating to the drop in glucose that you can. If the response is to strong as the patient improves, compensate with more IV dextrose *

Answer 51

_Management of Acute Cerebral Injury during DKA Management_ (1) Minimizing patient movement/agitation (2) Raising the head of the bed to 30 degrees with the patients neck midline *(helps with venous draining of the brain)* (3) **Cessation of hypotonic** fluids (4) **Cut**ting **IV fluids by 25 %** (assuming normal perfusion) (5) **5 mL/kg of 3%NaCl over 15 minutes** OR *0.5 g/kg Mannitol over 20 minutes* (6) **CALL PICU**

Hospital Pediatrics and Acute Care Flashcards

Updated 02/04/0224 (77 cards)