ORALS - PEDS Flashcards
PREPARE PEDS RESUS
- PPE
=> notify peds / PICU / peds pharmacist +/- trauma - Equipment
PPE
peds: broselow tape, weight based drug dosing reference chart, airway equipment for ____ year old child, IO kit
follow up questions
1. ETT sizing by age
2 yo - 2blade
8 yo - 3 blade
age/4 + 4 (uncuffed)
ETTX2 = NG / ETTX3 = DEPTH / ETTX4 = CHEST TUBE
- How to estimate weight
parents
broslow tape
formula (yrsx2 +10 / monts/2 + 4) - Normal BPS
1-10yrs agex2 + 70mmHg
10 or older: 90mmHg
NRP script
Pre-birth questions
- multiple gestations, gestational age
- MEC in SROM
- plan for delayed cord clamping?
- meds given / drugs taken
- maternal fever
- prenatal care / US
- PPE
=> notify peds / NICU / peds pharmacist +/- trauma - Equipment
PPE
Broslow tape
Drugs (epi)
newborn: vaginal delivery tray
Ohio warmer, umbilical line kit (3.5 - premies, 5 term)
hemostats / scissors for cord
neonatal airway (miller blade 0, ETT 3)
resus equip - NRP
Term + good tone + crying => mom for warming
If not:
=> warmer
within 60seconds
=> dry, stimulate, warm patient + clear secretions PRN
=> If HR 100 / gasping / apnea = PPV + SPO2 monitors
=> if HR not >100 after 15sec - MRSOPA
after 30seconds RA
=> HR>100 - continue post resus care
=> HR 60-100 - PPV (20/5), vent rate - 40-60/min
=> HR 60 - 1) intubate then 2) CPR (3:1 ratio, 100% FiO2, IV/UVC line)
after 60seconds RA
=> HR 60 - epi 0.01mg/kg IV (0.1mg/kg ETT) Q4min
=> consider hypovolemia, pTX as causes of arrest
FOLLOW UP QUESTIONS
1. What is MR SOPA
mask adjustment
reposition
suction
open mouth
pressure incr (PEEP 5 / PIP 20-40max)
adjuncts
- ETT tube by age
premature 2.5 uncuffed, blade 00
term 3 uncuffed, blade 00 - Endpoints / do not attempt NRP
ENDPOINTS - no signs of life for 20MIN (recent 2020 AHA)
don’t attempt;
=> premature (less 23wks / 400g)
=> ancephaly
=> chromosomal abnormalities incompatible w life
=> still born - BP by age
1mo old - 60mmHg
1-11mos - 70mmHg
no naloxone in neonates in NRP (just PPV + respiration)
=>naloxone can precipitate withdrawal and seizures in fetus in opioid dependent mothers
PALS VT/VF SCRIPT
- Resus team - PICU/additional ERP/peds pharmacist
2 large bore IVs / B/L tibial IOs if unable - Once cardiac pads are placed, pulse check and shock right away
=> defibrillate q2min with pulse + rhythm checks
=> 2J/kg => 4J/kg => 10J/kg - Proceed down VT/VF PALS algorithm
start with ongoing high quality CPR at a 15:2 ratio (2 providers) until airway is established then 20-30bpm
=> Rate 100-120
=> compression depth >1/3 AP diameter
=> minimal interruptions
=> full recoil
=> rotation of compressors Q2min
=> avoid excessive ventilation - Administer medications per PALS algorithm
epi 0.01mg/kg Q4min (0.1mg/kg via ETT)
amio 5mg/kg Q5min (max 3times)
consider lidocaine 1mg/kg then infusion - I would have ongoing ACLS with
=> pulse and rhyhtm checks Q2min
=> epi administered Q4min - Consider reversible causes
- ROSC (ETCO2 >40, spontaenous arterial pressure)
=> repeat set of vitals, ECG
=> Hypotension with pressors with MAP >65
=> appropriate sedation
=> Temperature management for normothermia, monitor with rectal or esophageal probes
=> foley for ins/outs
PALS UNSTABLE BRADY + PULSE
UNSTABLE (AMS, hypotension, shock)
- Resus team - PICU/additional ERP/peds pharmacist
2 large bore IVs / B/L tibial IOs if unable - HR less 60
=> oxygenate / ventilate
=> continues HR60 = start high quality CPR (15:2 until airway established)
=> Rate 100-120
=> compression depth >1/3 AP diameter
=> minimal interruptions
=> full recoil
=> rotation of compressors Q2min
=> avoid excessive ventilation - MGMT (if HR >60)
atropine 0.02mg/kg IV/IO (min dose 0.1mg) Q1min
epinephrine 0.01mg/kg IV/IO Q4min
transvenous / thoracic pacing
treat underlying cause
PALS UNSTABLE TACHY W PULSE
Wide vs Narrow complex
**Narrow Complex (less 90ms) **
=> look close for sinus tach (P waves, HR varies with activity), constant PR / variable RR
HR <220 (infants) / <180 (peds)
=> SVT (no p waves, HR does not vary)
HR >200 (infants) / >180 (peds)
MGMT
- vagal maneuvers
- adenosine 0.1mg/kg (max 6m) then 0.2mg/kg (max 12mg)
- synchronized cardioversion 1J/kg => 2J/kg
Wide Complex (>90ms)
=> UNSTABLE (AMS, hypotension, shock)
cardioversion (1J/kg => 2J/kg)
sedate with small dose midaz / fentanyl
=> ONGOING VTach
- amio 5mg/kg IV IO over 60min
- procainamide 15mg/kg IV/IO over 60min
BRUE SCRIPT
MGMT
- high risk = admission
- low risk = education +/- CPR training, EKG, r/o pertussis, monitor
follow up questions
1. Definition of BRUE
less than 1yr
Brief (1min)
Resolved (n vitals + exam)
Unexplained event (>1 of ABCT - aLOC, breathing (irreg, apnea), Cyanosis (pallor), Tone (hyper/hypo)
- Describe low risk BRUE (must have all):
1 episode, 1min
no CPR
normal PMDX / developemental/toxins
age >60days
term
normal exam / vitals
follow up questions
1. signs an infant death was 2’ intentional suffocation
hx of reucrrent ALTE / BRUE presentations (in care of same person)
hx of other infant deaths under care of same person
age >6mo
prev unexplained deaths in a sibling
simultaneous death of twins
blood on nose / mouth
signs of NAT
DDX UNWELL / IRRITABLE
fever in infant
- PPE/MOVID
accucheck
Monitors - co-oximetry
** BW:** trop, CK, myo
critical sample; lactate, glc, ketones, FFA, AA, insulin C peptide, ammonia, GH, carnitite, urea
cortisol
CRP/procalcitonin
septic work up - blood cultures, LP, UA/UCX, CXR, NPA
EKG
CXR
POCUS - MGMT - sepsis
Ampicillin 75mg/kg Q6H (listeria)
Gentamicin / tobra 5mg/kg Q24H (Chlamydia / gonorrhea)
if meningitis concern:
Cefotaxime 75mg/kg Q6H (GBS, E coli)
Acyclovir 20mg/kg TID - MGMT - inborn errors
NPO
D10W @ 6cc/kg/hr (higher rates needed) - MGMT - CAH
HC 25mg IV push
5cc/kg D10W => infusion at 4cc/kg/hr - MGMT - GI catastrophe
NG, low intermittent suction
fluid bolus PRN
intubate if suspected diaphragmatic hernia
follow up questions
- ddx for UNWELL infant: (misfits)
Trauma, accidental / NAT
Heart
Endocrine - DKA, CAH, thyroid
Metabolis - liver / bili
Inborn errors in metabolism
Sepsis
Formula mixed incorrect
Intestinal catastrophe
Toxins - one pill can kill ; CCB / TCA, sulfonylurea, opiates
Seizure - ddx for IRRITABLE infant (IT CRIES)
infections
trauma
congenital heart
reflux / rxn to meds - formula
insects
eyes - FB, corneal abrasion
strangulation - intra-ab / tourniquets
CONGENITAL CARDIAC CASE
2 WEEK OLD IN SHOCK vs 20day old CYANOTIC
- PPE / MOVID
accucheck
Monitors - co-oximetry
** BW:** trop, CK, myo
critical sample; lactate, glc, ketones, FFA, AA, insulin C peptide, ammonia, GH, carnitite, urea
cortisol
EKG: LVH or RVH (not normal)
CXR (boot - TOF, snowman - TAPVR, EGG - TCA, rib notching - coarctation)
POCUS (4 chambers)
2.Exam
**4 limb BP **(LE >UE normally, R>L >10mmHg = coarct)
Pre-post ductal sats (>3% btwn RU / RL extrem, less 94% in lower extrem / less 90% in any = clinically sig)
**femoral pulses **(absent / radial fem delay)
hyperoxia test (ABG, 100% FiO2 10min, ABG)
improvement = resp / no improvement = cardiac
>200 = PULM / 100 = CHD
careful - may close duct
- MGMT
**Abx: **
=> ampicillin 50mg/kg (listeria)
=> gentamicin 5mg/kg (chlamydia, gonorrhea)
=> cefotaxime 75mg/kg Q6H (GBS, Ecoli)
prostaglandin E1 (keep ductus arteriosus open, IF less than 1mo old) 0.1mcg/kg/min
O2 sat goal 85%
IVF 10cc/kg
PRESSORS
NE +/- epi
follow up questions
- list side effects of prostaglandin
Apnea MCC (30%)
Bradycardia
Hypotension
Fever
Seizures
Flushing
Decr plt aggregation
Risk for post-intubation CV collapse (PPV, intrathoracic pressure, decr VR) => use ketamine to maintain - Which congenital lesions result in SHOCK
Cyanotic shock: TGA, tet of fallot, tricuspid atresia, pulm atresia
Acyanotic shock: pulm stenosis, AS, coarctation - Congenital lesions that result in cyanosis
SHOCK: TGA (egg on a string), tet of fallot (boot shape), Tri atresia, pulm atresia, HRH
CHF: Truncus arteriosus, TGA, TAPVR (snowman), HLH - Congenital lesions that result in CHF
Truncus arteriosus, TGA, TAPR, HLH
VSD, ASD, PDA - Exam findings that defferentiate btwn cardiac vs resp cyanosis
**AGE **(>1MO - shunt / mixing, less = ductal)
**EXAM **
=> hepatomegaly (CHF)
=> fem pulses - absent / rad fem delay
=> 4 limb BP => Coarc if UE > LE by 15-20mmHg
=> pre-post ductal sats = difference = CHD (>3% R upper and R lower)
=> US = ?4 chambers
**COLOR **
pink = CHF babies / blue = terrible T babes (duct dependent) - DDX for a blue baby
congenital cardiac
respiratory - PNA, ARDS
sepsis
hemoglobinopathies (MetHb)
TET SPELL CASE
- PPE/MOVID
- identify trigger for decr in SVR
- MGMT: increase SVR (stop R=>L shunt)
=> knee to chest
=> supplemental O2
=> phenylephrine (incr SVR) 50-20mcg/kg - MGMT => stop hyperpnea (incr neg intrathoracic pressure = incr venous return= worse shunt)
=> ketamine 1-2mg/kg IV (3-5mg IM)
=> morphine 0.1mg/kg IV/IM OR fentanyl 1mg/kg - MGMT => fix acidosis
=> bicarb (fix hyperpnea) 1mEq/kg - MGMT => infundibular spasm (incr R=>L shunt + RVOT)
=> propranolol 0.25mg/kg - CONSULT
cardio
FOLLOW UP QUESTIONS
1. Describe triggers for a tet spell
=> acute decr in SVR (hypovolemia, tachycardia, defecation)
=> incr in PVR
HOCM CASE
- PPE/MOVID
ECG => dagger q waves (inferolateral), LVH, LAD, TWI (diffuse) - MGMT
=> IVF (if LV underfilled)
=> increased afterload: phenylephrine 5-20mcg/kg
=> consider BB to slow HR
=> stop inotropes to reduce hypercontractility
FOLLOW UP
1. Causes of exacerbations
inotropes
tachycardia
decreased afterload
hypovolemia
(anything that underfills LV)
COARCTATION CASE
> 7DAYS OLD, legs cyanotic, upper limb BP >15mmHg than lower limb BP
- PPE/MOVID
Broselow tape
** BW:** trop, CK, myo
critical sample; lactate, glc, ketones, FFA, AA, insulin C peptide, ammonia, GH, carnitite, urea
cortisol - EXAM:
4 limb BP (N LE >UE)
pre ductal / post ductal sats
=> PROX - R>L
=> DISTAL - U > L
Femoral pulses
POCUS - MGMT
PGE-1 0.1mcg/kg/min
pressors NE 0.1mcg/kg/min
inotropes - dobutamine 0.75mcg/kg/min - CONSULT
cardiology / cardiac surgery
PICU
Social work / spiritual care
RHEUMATIC FEVER CASE
- MGMT => ANTIBIOTICS
=> **PEN G benzathine **(27kg, less: 600 000 U IM vs 1.2 MIL U IM)
or
=> **amoxicillin **500mg X10d - MGMT => symptom control
arthralgia: NSAID/ASA (500mg po x14d)
carditis: diuretics (HF), glucocorticoids (severe carditis)
chorea: anticonvulsants
secondary prevention: 600 000 (27kg) IM Q3-4wks - CONSULTS
Rheumatology, peds
cardiology - ECHO
follow up questions
1. What is the JONES criteria
Joint arthralgia
Ocardiac- heart block, carditis
Nodules
Erythema marginatum
Sydenham chorea
Minor
CAFE P
CRP increase
Arthralgia
Fever
Elevated ESR
prolonged PR
- Need evidence of infection or previous infection, 2 major or 1 major and 2 minor
- What is the organism causing rheumatic fever
GABHS + pharyngitis
2’ exaggerated immune response to GAS
KAWASAKI CASE
MGMT
=> IVIG 2g/kg (reduce incidence of coronary aneurysms)
=>ASA 80mg/kg QID
=> steroids
=>CARDIO, RHEUM, PICU
What is the dx criteria for Kawaski (CRASH + BURN)
4/5 CRASH + 5days of fever
Conjunctivitis => non exudative, bilateral
Rash => generalized (trunk => face + extremities)
Adenopathy, 1.5cm
Strawberry tongue / mouth change (cracked lips, pharyngeal erythema)
Hands/feet erythema - peeling => swelling of hands / feet
Cardiac findings => Prolonged PR, non specific ST/T wave changes
CAH CASE
CASE: N/V/D, hypotension / hypovolemic shock
hyperK +/- hypoNa, met acidosis, hypoGlc
- PPE / MOVID
accucheck
Monitors - co-oximetry
** BW:** trop, CK, myo
critical sample; lactate, glc, ketones, FFA, AA, insulin C peptide, ammonia, GH, carnitite, urea
cortisol
EKG
CXR
POCUS - EXAM
Females - clitoral enlargement, labial fusion
Males - normal to dark scrotum + enlarged phallus - MGMT
shock NS 20cc/kg bolus => 60cc/kg in 2H
hypoglycemia D10W 5-10cc/kg
steroids: HC 2-3mg/kg
=> 25mg (3yrs) / 50mg (>3) / 100mg (adults)
hyperkalemia: IVF / HC, check ECG to see if requires shifting - consults
ENDO => newborn screening, ACTH stim test, genetic testing, adrenal US
NAT
- PPE/MOVID
=> AST/ALT (>80 => consider CT)
=> CBC/INR-coags, LFTs, critical sample - MGMT
skeletal survey (yrs 2-5)
TBI concern - CT head, MRI, optho
FOLLOW UP QUESTIONS
1. findings of NAT
cigarette burns, bite marks
restraints
immersion
bruising in non ambulatory
patterned brusing, posterior auricular brusing
posterior oropharyngeal bruising, neck brusiing
fractures in diff stages of healing
skull, scapular, long bone fractures
spinous process fractures
posterior rib fractures
humeral fracutres
bucket handle / metaphyseal fractures
