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Notes from Handbook Flashcards

1
Q

What is the difference between stridor and stertor?

A

Stridor is caused by turbulent air flow in or below the larynx
Stertor is caused by turbulent air flow above the larynx (IE pharynx, nasopharynx, soft palate)

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2
Q

When may stertor occur relating to neurological conditions?

A

In the post ictal phase following a tonic clonic seizure

Vagal or hypoglossal nerve damage e.g. Stroke, tumour

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3
Q

Why is I&V often used in seriously ill kids even without an ‘at risk’ airway? 3 reasons

A

To reduce metabolic demands of body
To maintain tight control over physiology e.g. For neuroprotection
When anticipating progression of illness e.g. Pulmonary oedema

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4
Q

What is the triad of Pierre-Robin sequence?

A

Cleft palate
Retrognathia
Glossoptosis

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5
Q

What is retrognathia?

A

Abnormal positioning of the maxilla or (usually) mandible - ‘overbite’

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6
Q

What is glossoptosis?

A

Airway obstruction caused by backwards displacement of the tongue base

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7
Q

How does the Pierre Robin sequence arise?

A

Micro/retrognathia causes glossoptosis, causing upper airway obstruction and usually cleft palate (failure of fusion of hard palate)

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8
Q

What is Stickler Syndrome?

A

Hereditary progressive arthro-ophthalmopathy
CTD of collagen causing ‘flattened’ facial appearance (Pierre Robin), eye problems, hearing problems and infections, arthritis

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9
Q

How is Stickler Syndrome inherited?

A

AD

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10
Q

Eye problems associated with Stickler Syndrome?

A 
High myopia
Ocular hypertension and glaucoma
Cataract
Retinal detachment
Classical vitreous findings
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11
Q

How do you size a Guedel airway?

A

From middle of lips to angle of jaw

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12
Q

When are nasopharyngeal tubes particularly useful?

A

For upper airway anomalies

Tolerated in awake patients

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13
Q

2 contraindications to nasopharyngeal tube use?

A

Base of skull fracture (suspected)

Coagulopathies

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14
Q

3 methods of NIV?

A

Optiflow
Facial BiPAP
Nasal CPAP

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15
Q

When is NIV used?

A

Often first for kids in need of respiratory support e.g. Bronchiolitis
As alternative to invasive ventilation when that is high risk e.g. Oncology patients

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16
Q

Examples of conditions requiring long term NIV?

A 
Neuromuscular e.g. DMD, SMA
Neurodisability e.g. Recurrent aspiration, poor inspiratory reserve, scoliosis/chest shape abnormalities
Obstructive sleep apnoea
Central hypoventilation
Craniofacial abnormalities 
Airway malacia
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17
Q

What is the first step in intubation?

A

Establishing a secure airway

ETT (nasal or oral) or Tracheostomy

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18
Q

What is stertor?

A

Heavy snoring/gasping respiratory sound caused by partial airway obstruction above the level of the larynx

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19
Q

What is PIP?

A

Peak Inspiratory Pressure

The highest level of pressure applied during inspiration measured in cmH2O

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20
Q

What is PEEP?

A

Peak End Expiratory Pressure
The pressure applied to the lungs during and after expiration until PIP kicks back in; needed to maintain small airway and alveolar patency

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21
Q

What is delta P/ the distending pressure?

A

PIP - PEEP Determines tidal volume, which varies based on lung compliance

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22
Q

What limit is applied to the size of breaths made by ventilation in order to avoid lung barotrauma?

A

Less than 7 ml/kg/breath

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23
Q

What are the 2 broad types of ventilation?

A

Pressure control, where PIP and PEEP are set

Volume control, where volume control and PEEP are set

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24
Q

What does tidal volume depend on in pressure limited/controlled ventilation?

A

Patient’s lung compliance

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25
What varies in volume limited/volume control ventilation?
PIP - we set tidal volume and PEEP, and changes in patient's lung compliance are managed by the ventilator changing the PIP
26
4 modes of ventilation (how and when breaths are provided or supported)?
Continuous mechanical ventilation CMV Synchronised Intermittent Mandatory Ventilation SIMV Pressure support PS High Frequency Oscillatory Ventilation HFOV
27
What 2 variables govern oxygenation levels?
Inspired oxygen concentration | Mean airway pressure (via altering surface area for gas exchange)
28
What 2 variables is CO2 clearance dependant on?
Tidal volume X respiratory rate (= minute volume, in L/min)
29
DOPES of causes of difficult ventilation or sudden deterioration?
Displaced ETT - auscultate and look at CO2 Obstructed ETT - secretions, plugs, clots, misplaced tube Pneumothorax - percuss and auscultate... CXR Equipment failure Stomach - gas filled stomach (kid should always have NG tube in)
30
5 aims of anaesthesia in kids who are being ventilated?
``` Achieve hypnosis Achieve amnesia Achieve haemodynamic stability Adequate muscle relaxation Facilitate treatment in ICU ```
31
5 examples of induction agents for anaesthesia?
``` Ketamine Thiopentone Benzodiazepines Opioids Propofol ```
32
How does ketamine work and therefore what is it useful for?
Sympathomimetic effects - good for the haemodynamically unstable or hypovolaemic Also bronchodilator so useful in severe asthma Analgesic
33
2 contraindications to ketamine use in kids?
Severe septic shock - paradoxical effect on hypotension | Raised intracranial pressure
34
What is thiopentone used for in kids?
Strong antiepileptic effects so good for rapid sequence induction in status
35
Contraindication to thiopentone use?
Severe sepsis - hypotension
36
What are benzodiazepines mostly used for in ICU?
Maintenance of anaesthesia e.g. Midazolam infusion | Or induction agents at higher dose alongside opioids
37
What is the preferred maintenance drug for sedation in neonates? What is avoided?
Opioids best | Benzos are avoided
38
What can Propofol cause in septic or hypovolaemic patients?
Myocardial depression and hypotension
39
What is suxamethonium?
Depolarising agent used as a muscle relaxant
40
How quickly does suxamethonium work?
About 30 seconds
41
What is suxamethonium used for?
Rapidly securing airway after induction of anaesthesia - e.g. To prevent regurgitation of gastric contents
42
Two examples of non-depolarising agents?
Vecuronium | Atracurium
43
Which non-depolarising muscle relaxant is used at induction and as boluses for short procedures?
Atracurium
44
When is the peak effect of a morphine bolus?
10 minutes
45
When is fentanyl used for sedation and pain relief?
When pruritis is a big problem with morphine | Where morphine has not worked adequately
46
How quickly does fentanyl work following a bolus?
Peak effect is at 2-3 minutes
47
What is Chloral Hydrate?
Sedative and hypnotic | Used for pre-procedure sedation e.g. Prior to a CT scan on Paeds wards
48
What drug is often used as a sedative and hypnotic prior to procedures e.g. a CT scan?
Chloral hydrate
49
What is alimemazine?
Phenothiazine derivative used as a sedative, hypnotic, anti-emetic and anti-pruritic
50
Side effects of alimemazine?
EPSEs - dystonia, tardive dyskinesia
51
What is clonidine?
Central alpha-2 adrenergic agonist - a sympatholytic | Lower BP and cause bradycardia but little impact on respiratory drive so useful as a sedative
52
What drug is useful to minimise side effects from opioid or benzo withdrawal?
Clonidine
53
What is dexmedetomidine?
Specific central acting alpha-2 adrenergic receptor agonist with minimal respiratory depression
54
2 examples of centrally acting alpha-2 adrenergic agonists used in sedation in kids?
Clonidine | Dexmedetomidine
55
What is the risk of giving Propofol via infusion in kids?
Propofol infusion syndrome - metabolic acidosis, hyperK, Hyperlipidaemia, rhabdomyolysis, organ failure
56
What is the role of steroid use in severe sepsis?
Adjunct when BP remains low despite maximum IV inotrope infusion (inotrope unresponsive septic shock) - probably occult adrenal insufficiency contributing therefore exogenous steroids help
57
Which steroid is often used as a post-op or post-chemo anti emetic?
Dexamethasone
58
Which corticosteroid is only available PO?
Prednisolone
59
Which catecholamine has the biggest effect on increasing systemic vascular resistance when given via central line?
Noradrenaline
60
Which catecholamine has the strongest chronotropic and inotropic effect when given via central line?
Adrenaline
61
What is milrinone? What effect does it have?
Phosphodiesterase inhibitor | Used to decrease systemic vascular resistance
62
2 reasons why inotropes need to be given via central line? Exception?
To avoid tissue necrosis when extravasation occurs To achieve adequate delivery into circulation Dopamine is the exception
63
What does central venous pressure measure?
Right atrial pressure; right ventricular end diastolic pressure
64
What is IVH?
Intraventricular haemorrhage - often a comorbidity in neonates as any condition causing clotting abnormalities can contribute
65
9 methods of supporting cerebral autoregulation to prevent secondary brain injury?
Positioning - head in midline, 30 degrees elevated Normothermia Normoglycaemia Sedation Noradrenaline vasopressor (to maintain CPP) PCO2 control Oxygenation over 10kPa Electrolyte control (Na 140-145) Phenytoin in severe injury to prevent seizures
66
How do you work out fluid requirements for kids?
100mls/kg for first 10kg (up to 1L) 50mls/kg for next 10kgm(up to 500ml) 20mls/kg thereafter Over 24 hours
67
Max fluid for females and males per 24 hours?
2L/day for females | 2.5L/day for males
68
What fluid is used for maintenance on PICU?
0.45% NaCl + 5% glucose
69
What fluid is used for maintenance in head injury or hyponatraemia?
0.9% saline
70
What fluid is used for neonates?
10% glucose + electrolytes
71
What fluid is used for raised ICP and how is it given?
3% NaCl - boluses
72
What fluid is given in fluid resus and how?
4.5% HAS - boluses
73
What is normal plasma osmolality?
290-310 mosmol/Kg
74
How is plasma osmolality calculated?
2[Na] + 2[K] + [glucose] + [urea]
75
4 indications to start renal replacement therapy?
Refractory hyperkalaemia Fluid overload with anuria Acidosis, uraemia, neurological impairment Certain inborn errors of metabolism
76
Which are the 2 most commonly used RRT methods on PICU?
Peritoneal dialysis | Continuous Veno-Venous Haemofiltration (CVVH)
77
What equipment is needed for CVVH and who does this therefore limit use on?
Vascath (large cannula) - increasingly difficult the smaller the baby is and can also cause cardiovascular instability
78
What is leukapheresis and what is it used for?
Separating white blood cells from whole blood | Useful for e.g. Reducing WCC in a kid with leukaemia
79
What is the biggest risk of TPN use?
Central venous/long lines - infection and technical problems with line
80
What type of feed is used for kids with cows milk protein intolerance, lactose intolerance, allergy or eczema?
Hydrolysed formula
81
What is elemental formula used for?
Short bowel syndrome, CF, malabsorbative conditions
82
What is Medium Chain Triglyceride feed used for?
Chylothorax
83
What is Medium Chain Triglyceride feed and branched chain amino acids used for?
Liver disease

GOSH (6 decks)

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